342701159-5-5-2025-27-AS-KHOS-DGPN4S-20250515100824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701159
Report Date: 05/05/2025
Date Signed: 05/05/2025 04:21:29 PM

Unsubstantiated

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
10/11/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20241011104737

FACILITY NAME:	BEATRICE SENIOR CARE		FACILITY NUMBER:	342701159
ADMINISTRATOR:	CLARK, TIMOTHY		FACILITY TYPE:	740
ADDRESS:	8901 MELODIC CT		TELEPHONE:	(916) 270-3961
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	05/05/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Beatrice Clark		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Injections being administered by unqualified staff.
Staff not maintaining residents hygiene.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with licensee Beatrice Clark and explained the purpose of the visit.

This investigation consisted of observation, record review and interviews. Interviews were conducted with six residents (R1-R6), two staff members (Clark and S1), a resident's attorney-in-fact (R1's POA), and a resident's friend.

LPA Moleski reviewed a medication list for R1 from November 2024. R1 did not have a prescription for insulin or any other injections. In an interview, R1's POA said that R1 is not currently taking injections, and has not since the time of their admission to this facility. R1 was admitted in March 2024, according to their admission agreement. In an interview, R1 said they do not receive injections at this facility. In an interview, R1's friend said they had not seen R1 being given injections. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20241011104737

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: BEATRICE SENIOR CARE	FACILITY NUMBER: 342701159
	VISIT DATE: 05/05/2025

NARRATIVE

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Staff members interviewed said that R1 does not receive any injections at this facility. Other residents interviewed said they had not witnessed R1 receiving any injections.

LPA Moleski inspected medication storage areas for R1's medications and observed one insulin shot with prescription instructions for it to be used in an emergency. The shot was dated July 2024 and expires this July.

LPA Moleski observed all six residents during this visit to be reasonably clean and hygienic. R1 appeared to be wearing clean clothes. LPA Moleski observed no odor of urine or feces. In an interview, R1's POA said that R1 is well taken care of at this facility. In an interview, R1's friend said that R1 had never received a bath while living at this facility, although they had never smelled anything from this resident or any other. R1's friend also said that R1 not changed, although staff do clean R1. In an interview on 10/16/24, R1 said they were bathed the day prior. In that same interview, R1 said they are changed regularly. Interviews with two other residents who are able to speak indicated that residents are kept clean and are taken care of by staff.

The department has determined the following as it relates to the allegations that injections are being administered by unqualified staff and that staff are not maintaining a resident's hygiene:

Based on interviews, observation and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding these allegations. An exit interview was held and a copy of this report was left with Clark.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

LIC9099 (FAS) - (06/04)

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