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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701191
Report Date: 06/14/2024
Date Signed: 06/14/2024 02:08:38 PM

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
06/13/2024 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20240613165603
FACILITY NAME:CA CARING HANDSFACILITY NUMBER:
342701191
ADMINISTRATOR:MICHAEL JANKOWSKIFACILITY TYPE:
740
ADDRESS:8797 TWINBERRY WAYTELEPHONE:
(916) 667-3248
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
06/14/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Michael JankowskiTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility did not provide resident records upon request
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegation on 6/14/24 at 12:15pm. LPA met with Caregiver Arinanne Dagohoy who contacted the Administrator regarding the purpose of the visit. LPA interviewed Administrator #1 (Adm 1) and (Adm 2) and Staff 1 (S1) during this visit. The investigation revealed that a copy of the residents file was not provided to the attorney of resident #1 (R1).

Based on confirmation through interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED.
Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.
Substantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
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-20240613165603
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: CA CARING HANDS
FACILITY NUMBER: 342701191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2024
Section Cited
CCR
87468.2(a)(2)
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Additional Personal Rights of Residents in Privately Operated Facilities
In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To have their records and personal information remain confidential and to approve their release, except as authorized by law.
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Licensee/Administrator shall submit a complete copy of the residents file to the attorney by POC due date. Confirmation of completion shall be faxed to the office.
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This requirement is not met as evidenced by: Based on interviews confirming Administrator did not provide a copy of R1's file upon request by R1's attorney. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC9099 (FAS) - (06/04)
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