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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701176
Report Date: 12/06/2024
Date Signed: 12/06/2024 11:05:27 AM

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
11/19/2024 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241119095703
FACILITY NAME:CISTERS LOVING CARE HOME IIFACILITY NUMBER:
342701176
ADMINISTRATOR:FUENTES, FLORINDAFACILITY TYPE:
735
ADDRESS:5316 NECTAR CIRCLETELEPHONE:
(916) 897-3834
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:4CENSUS: 4DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Florinda Fuentes TIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff do not treat residents with respect
Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA was later met by Administrator Florinda Fuentes.

The investigation consisted of records review, resident interviews (R1 - R3), and staff interviews (S1- S4). The following has been determined as it relates the aforementioned allegations.

On 11/19/2024, The Department received allegations that Staff 3 (S3) and Staff 4 (S4) called R1 "a derogatory name and beat up" R1 on 11/18/2024.

On 11/21/2024, LPA Valerio conducted an on-site visit to the facility .
Continues on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 2
Control Number 27-AS-20241119095703
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: CISTERS LOVING CARE HOME II
FACILITY NUMBER: 342701176
VISIT DATE: 12/06/2024
NARRATIVE
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Continued from LIC 9099

On 11/21/24, LPA attempted to interview R1 three (3) times. R1 denied to participate in the interview. LPA Valerio interviewed R2. R2 was in the room when the alleged incident occurred. R2 reported hearing the staff call R1 the derogatory name and were encouraging R1 to hit the walls harder. R2 did not observe R1 being hit by staff. R2 reported being hit by R1 after R1 entered R2's room. LPA Valerio attempted to interview R3; however, due to communication barriers, the interview was deemed unsuccessful.

On 11/21/24, LPA Valerio interviewed S1 and S2. S1 and S2 deny the allegations to be true. S1 believes all the staff are good but S1 cannot speak on what happened as S1 was not present. S2 stated staff treat residents with respect. S2 reported having a good rapport with all the residents.

LPA Valerio reviewed a shared information report/ Unusual Incident report dated 11/18/2024. Based on the information, S3 and S4 were present during overnight shift when R1 expressed behaviors that were a potential danger to self and other peers/staff. The episode lasted from 12:00 AM until R1 went to the Day Program. The report did not share any details of force used or name calling by staff towards residents in care. The report did indicate R1 making threats to staff, R1 engaging in aggressive acts towards self, staff, and peers, and staff attempting to redirect and calm R1.

On 12/04/2024, LPA Valerio interviewed S3. S3's statement align with what was reported on the incident report. S3 stated the allegations are untrue and it is actually R1 who hit staff. S3 reported trying to calm R1 and figuring out why R1 was agitated. LPA Valerio interviewed S4. S4 stated staff only say things to residents that will de-escalate the situation. Staff stated they understand if they say bad things, it will escalate the situation. S4 stated R1 is the person who hit staff and another resident. S4 reported if they need to assist residents, the staff will ask consent before assisting with ADLs.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, no deficiencies are being cited. An exit interview was held and a copy of report was left at the facility with Administrator F. Fuentes
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2