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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701158
Report Date: 01/14/2025
Date Signed: 01/15/2025 08:24:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241105143730
FACILITY NAME:LIVING HOPE ONEFACILITY NUMBER:
342701158
ADMINISTRATOR:LIVINGSTONE, JACQUELINEFACILITY TYPE:
735
ADDRESS:4801 34TH STTELEPHONE:
(916) 745-5716
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:12CENSUS: 9DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jacqueline Livingstone TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Staff are allowing client in care to leave the facility unassisted
Staff do not answer the phone
Staff do not ensure resident has clean bed linens
INVESTIGATION FINDINGS:
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On 1/14/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Staff Member (SM), Wendy Zeng and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings for the allegations above. LPA asked that SM Zeng call the Facility Designated Administrator (FDA), Jacqueline Livingstone to inform them that CCL was present.

Current census is 9. A brief interview with FDA was conducted.
Allegation: Staff are allowing client in care to leave the facility unassisted.
It was alleged that staff are allowing client in care to leave the facility unassisted. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted it was learned that staff do allow R1 to leave the facility unassisted as most residents are allowed to leave. However, based on record review R1’s physician report dated on 09/23/2023 states that the resident is not allowed to leave the facility unassisted. Based on the information gathered, the facility did allow client in care to leave the facility unassisted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 27-AS-20241105143730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LIVING HOPE ONE
FACILITY NUMBER: 342701158
VISIT DATE: 01/14/2025
NARRATIVE
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Allegation: Staff do not ensure resident has clean bed linens

It was alleged that staff do not ensure resident has clean bed linens. During the course of this investigation, LPA toured the facility on 11/14/2024 and 11/27/2024. On 11/14/2024 and 11/27/2024, LPA observed that the linen closet had around 4 bedsheets, 4 fitted sheets, and 8 towels. During these visits, LPA also observed that bedrooms 2 and 3 did not have any type of bed linens on the bed. LPA asked facility staff if there were any other linens available for residents in case they needed additional linens due to any accidents or if they needed to be cleaned. Facility staff stated no and those were the only linens available. Based on the information gathered, the facility did not ensure resident has clean bed linens.

Allegation: Staff do not answer the phone

It was alleged that staff do not answer the phone. During the course of this investigation, LPA called the facility phone on 5 separate occasions, on 11/13/2024, 11/14/2024, 11/26/2024, 11/27/2024 and 12/10/2024. On all occasions the LPA was not able to reach anyone while calling the facility phone. In addition, LPA called the Facility Designated Administrator and House Manager several times on 11/14/2024 and 11/18/2024 however was unable to reach them. LPA also conducted interviews from outside parties and found that they too had issues with reaching the facility via telephone. Based on the information gathered, the facility did not ensure staff do not answer the phone.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

An immediate civil penalty was provided today in violation of care and supervision 85078(a)(1).

An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the Facility Designated Administrator at the end of this visit.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241105143730

FACILITY NAME:LIVING HOPE ONEFACILITY NUMBER:
342701158
ADMINISTRATOR:LIVINGSTONE, JACQUELINEFACILITY TYPE:
735
ADDRESS:4801 34TH STTELEPHONE:
(916) 745-5716
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:12CENSUS: 9DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jacqueline Livingstone TIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
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3
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5
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7
8
9
Staff are not providing proper medication assistance to client in care
Staff do not assist resident with hygiene as needed
Staff do not assist resident with grooming as needed
Staff do not maintain resident's room clean
INVESTIGATION FINDINGS:
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5
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10
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On 11/14/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Staff Member (SM), Zeng and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings for the allegations above. LPA asked that SM Zeng call the Facility Designated Administrator (FDA), to inform them that CCL was present.
Current census was 9. A brief interview with FDA was conducted.
Allegation: Staff are not providing proper medication assistance to client in care.
It was alleged that staff are not providing proper medication assistance to client in care. During the course of this investigation, LPA reviewed facility documentation and conducted staff and resident interviews. An interview with 3 staff members were conducted. 3 out 3 staff members deny that they do not provide proper medication assistance to clients in care. 3 out 3 staff members state that all residents come and take their medication near the office where medication is held. 3 out 3 staff members state that some residents may deny to take their medication but that is documented in their file. An interview with 7 residents were conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20241105143730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LIVING HOPE ONE
FACILITY NUMBER: 342701158
VISIT DATE: 01/14/2025
NARRATIVE
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7 out 7 residents state that they get their medication in the morning, evening and after dinner near the office. 7 out 7 residents state that they believe that they are obtaining the correct medication. 7 out 7 residents report no issues with their medication. A review of the facilities Medication Administration Record (MAR) did not have any indication to show that the staff are not providing proper medication assistance. A review of the facilities resident files were conducted also did not have documentation to reflect that staff are not providing proper medication assistance to client in care. Based on the information gathered, it is unclear if the staff are not providing medication assistance to client in care.

Allegation: Staff do not assist resident with hygiene as needed and Staff do not assist resident with grooming as needed.

It was alleged that staff do not assist resident with hygiene and grooming as needed. During the course of this investigation, LPA reviewed facility records and conducted staff and resident interviews. 3 out 3 staff members deny not assisting resident with hygiene or grooming as needed. 3 out 3 staff members state that they assist by reminding residents to ensure that they have proper hygiene and groom themselves. 3 out 3 staff members state that most residents do their own hygiene and grooming needs. An interview with 7 residents were conducted. 7 out 7 residents state they do take their own showers and groom themselves and will ask for assistance when needed. 7 out 7 residents state that they do not have issues when they ask for assistance. A review of the facilities residents records were conducted. All resident records state that residents can conduct their own hygiene needs however will need prompting as needed. Based on the information gathered it is unclear if the staff do not assist resident with hygiene or grooming as needed.

Allegation: Staff do not maintain resident's room clean

It was alleged that staff do not maintain resident’s room clean. During the course of this investigation, LPA conducted facility tours and conducted staff and resident interviews. Based on 3 staff interviews, 3 out 3 staff members deny that they do not maintain resident’s room to be clean. 3 out 3 staff members state that they assist residents to maintain and clean their rooms on a daily basis with reminders as well as daily chores conducted by staff. 7 residents interviewed were interviewed. 7 out 7 residents state that they have assistance from staff to help clean their rooms. 7 out 7 residents state that they can clean their own rooms and prefer to clean themselves. LPA conducted a tour of the facility rooms on 11/14/2024 and 11/27/2024 and did not observe that the rooms were not maintained or clean at the time of the LPAs visit. Based on the information gathered, it is unclear if the staff do not maintain residents room clean.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20241105143730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LIVING HOPE ONE
FACILITY NUMBER: 342701158
VISIT DATE: 01/14/2025
NARRATIVE
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As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20241105143730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIVING HOPE ONE
FACILITY NUMBER: 342701158
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
CCR
85078(a)(1)
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(a)In addition to Section 80078, the following shall apply:
(1)The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This is not met as evidenced by: Based on interview and record review the Licensee did not ensure that the residents needs were by not ensuring that they did not leave unassisted.
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 Facility Administrator stated that a review of the section, will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at
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. It was learned that the residents physician report stated that the resident was not allowed to leave the facility unassisted however based on staff interviews they allowed R1 to leave unassisted. This poses an immediate health,safety, and personal rights risks to persons in care.
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arielle.pascua@dss.ca.gov. by the due date COB. Information submitted must include attendees, trainers, and information discussed.
Type B
02/14/2025
Section Cited
CCR
80088(g)
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(g) The licensee shall provide linens of various kinds necessary to meet the program of services being offered by the facility and the requirements specified in Chapters 2 through 7.
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 Facility Administrator stated that a review of the section, will be conducted.
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This is not met as evidenced by: Based on interview and observation, the Licensee did not ensure that the residents were accommodated with clean linens at all times. This poses a potential health, safety, and personal rights risks to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20241105143730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIVING HOPE ONE
FACILITY NUMBER: 342701158
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
85072(b)(9)
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(9) To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies.
This is not met as evidenced by:
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A statement of correction shall be submitted to the LPA by POC date.
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Based on observation, the licensee did not ensure that the facility telephone was answered during the times of 11/13/2024, 11/14/2024, 11/26/2024, 11/27/2024 and 12/10/2024. This poses a potential health, safey and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7