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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701228
Report Date: 10/06/2023
Date Signed: 10/06/2023 08:59:36 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
09/19/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230919110101
FACILITY NAME:COMFORT LIVING ELDER CARE 3FACILITY NUMBER:
342701228
ADMINISTRATOR:SOUMAHORO, MARIAM GFACILITY TYPE:
740
ADDRESS:8765 INISHEER WAYTELEPHONE:
(510) 409-7096
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Abietuwaja EdokpolorTIME COMPLETED:
09:10 AM
ALLEGATION(S):
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Staff do not keep the facility free from pests
Staff are not providing adequate care and supervision to the residents
INVESTIGATION FINDINGS:
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On 10/06/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff, Abietuwaja Edokpolo and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5. A brief interview was conducted with care staff. LPA Lee also read the report findings to administrator, Mariam Soumahora, via telephone because administrator was not present during today’s visit. At 8:30 AM, LPA Lee toured the facility with care staff. LPA Lee also reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Allegation: Staff do not keep the facility free from pests.
It was alleged that the staff did not keep the facility free from pests. This investigation consisted of records reviewed, interviews with staff and residents. It was learned that 4 out of 5 residents had not witnessed any pest in the facility and has no concerns.
Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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-20230919110101
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: COMFORT LIVING ELDER CARE 3
FACILITY NUMBER: 342701228
VISIT DATE: 10/06/2023
NARRATIVE
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The investigation also revealed that 3 out of 3 facility staff denies seeing any pest in the facility. It was learned that the facility is receiving pest control services from “California Pest Control.” The facility received services on 08/14/2023 from 4:55 to 5:45 PM, 08/29/2023 from 4:48-5:38 PM and 09/19/2023 from 3:21-3:34 PM. Per LPA Lee visit and tour of the facility on 09/26/2023 and today’s visit, LPA Lee did not observe any pest in the facility.

Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff do not keep the facility free from pests.

Allegation: Staff are not providing adequate care and supervision to the residents.

It was alleged that the staff are not providing adequate care and supervision for the residents. This investigation consisted of records reviewed, interviews with staff and residents. It was learned that 4 out of 5 residents has not witnessed any facility staff not providing adequate care and supervision to the resident. It was also learned that 4 out of 5 residents have no concerns regarding care and supervision. The investigation also revealed that 3 out of 3 facility staff denies not providing adequate care and supervision to the residents.

Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff are not providing adequate care and supervision to the residents.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2