342701248-3-7-2024-27-AS-KHOS-D3HPQN-20240319113125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701248
Report Date: 03/07/2024
Date Signed: 03/07/2024 10:30:40 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
12/15/2023 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231215155605

FACILITY NAME:	SACRAMENTO SENIOR LIVING II		FACILITY NUMBER:	342701248
ADMINISTRATOR:	LEWIS, SALOTE		FACILITY TYPE:	740
ADDRESS:	34 LOMA MAR CT		TELEPHONE:	(530) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 6	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Misivono Qadroka		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Personal Rights: Facility staff touched a resident inappropriately

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kevin Gould made an announced inspection to the Sacramento Senior Living II RCFE on 3/7/24 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Misivono Qadroka and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations because R1, in discussing the allegations over two interviews clarified that he was initially uncomfortable with a staff member of the same gender assisting with bathing but has come to understand that staff is only assisting with daily living and is not a sexual act. R1 states they have made adjustments to bathing and R1 can wash his body with assistance of staff. Staff interviewed denied any issues with bathing and that R1 prefers to wash parts of himself and there have been no issues. S1 states R1's physician reports and needs and services plan R1 requires assistance with bathing. Per file review R1's 602 does indicate that R1 needs assistance with bathing.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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-20231215155605

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: SACRAMENTO SENIOR LIVING II	FACILITY NUMBER: 342701248
	VISIT DATE: 03/07/2024

NARRATIVE

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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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