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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701248
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:46:02 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
05/08/2024 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240508134903
FACILITY NAME:SACRAMENTO SENIOR LIVING IIFACILITY NUMBER:
342701248
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Melvin HindsTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not administer resident's medication
INVESTIGATION FINDINGS:
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On 7-25-24 at 12:47pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss investigative findings for the allegation noted above. LPA met with lead caregiver Melvin Hinds and explained the purpose of the visit. Administrator Salote Lewis was notified via phone of LPA's visit and purpose and gave permission for lead caregiver to sign in her absence.
Allegation: Staff did not administer resident's medication. During this investigation, LPA conducted interviews with four residents and Administrator. LPA also reviewed facility file documentation including medication log sheets. Additionally, LPA conducted a facility observation on 7-19-24. LPA Truong conducted additional investigation for this allegation. Based on record review, it was revealed that facility staff did not administer as prescribed eye drop medication for resident5 (R5) on 6/28/2024 at 12pm, 4pm, an 8pm. Based on record review, it was revealed that medication Amlodipine 5mg was not administered as prescribed to R5 on 6/28/24. No additional documentation to describe reasons for R5 not receiving these medications was available. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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 6
Control Number 27-AS-20240508134903
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: 07/25/2024
NARRATIVE
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As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6. An exit interview was conducted with lead caregiver and a copy of this report was provided to lead caregiver. Appeal rights provided. LIC 811 provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
05/08/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240508134903

FACILITY NAME:SACRAMENTO SENIOR LIVING IIFACILITY NUMBER:
342701248
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Melvin HindsTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff made inappropriate comments towards residents
Staff did not assist resident in a timely manner
Staff did not meet resident's bathing needs
Staff did not safeguard resident's personal belongings
Staff inappropriately video recorded resident
Staff did not provide a comfortable and safe environment for resident
Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
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On 7-25-24 at 12:47pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver investigative findings for the allegations noted above. LPA met with lead caregiver Melvin Hinds and explained the purpose of the visit. Administrator Salote Lewis was notified via phone of LPA's visit and gave permission for lead caregiver to sign in her absence. During this investigation, LPA conducted interviews with four residents and Administrator. LPA also reviewed facility file documentation including current facility menu, theft and loss policy, and resident care logs. Additionally, LPA conducted a facility observation on 7-19-24. LPA Truong conducted additional investigation for these allegations.

Allegation: Staff made inappropriate comments towards residents. LPAs conducted interviews, observation, and record reviews as stated above. Based on observation conducted, it was revealed that staff did not make inappropriate comments towards residents. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240508134903
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: 07/25/2024
NARRATIVE
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Additionally, it was revealed through interviews that no corroborated statements existed which describe staff making inappropriate comments towards residents. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff did not assist resident in a timely manner. LPA conducted interviews, observation, and record reviews as noted above. Based on interviews and record reviews, it was revealed that staff are assisting residents as needed within appropriate amounts of time and providing adequate supervision during assistance. LPA’s observation did not reveal an inadequate response time to residents’ needs. Record reviews indicate staff are meeting residents’ needs timely in various activities of daily living (ADL) components. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff did not meet resident’s bathing needs. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that staff are performing bathing assistance in an adequate and timely fashion. Records reviewed indicated various type of bathing needs for residents. These records indicate staff is completing bathing assistance needs for residents in care. Additionally, interviews did not reveal corroborated statements of staff not meeting residents’ bathing needs. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff did not safeguard resident’s personal belongings. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that Licensee maintains documentation adequate for tracking residents’ personal belongings along with options for residents’ to record what personal items are brought in and removed. Additionally, interviews conducted did not reveal any corroborated statements of staff mishandling or otherwise not safeguarding residents’ personal belongings. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. {Cont. on 9099C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240508134903
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: 07/25/2024
NARRATIVE
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Allegation: Staff inappropriately video record residents. LPA conducted interviews and observations as noted above. Based on interviews conducted, there were no corroborated statements which revealed facility staff recording residents with any devices including wall mounted cameras or cell phones. LPA’s observation did not reveal the presence of any recording devices inside or outside of facility. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff did not provide a comfortable and safe environment for resident. LPA conducted interviews and observations as noted above. Based on observation, facility at this time maintains adequate furniture and furnishings throughout with adequate lighting and functional devices necessary for resident comfort and safety. Observation revealed no obstruction to fire exits and dangerous items were secured and inaccessible to residents in care. Interviews conducted did not reveal any corroborated statements of staff not providing a safe and comfortable environment. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff are not providing adequate food service to residents. LPA conducted interviews, observation, and record reviews as noted above. LPA compared current facility menu to food items on hand. LPA observed food items in appropriate quantities and able to match established menu items. Additionally, menu reviewed contains various food choices as well as snacks available to residents throughout the day. Established food items contain the regulatory required nutrition available to residents. Interviews conducted revealed facility staff is providing a variety of food choice between breakfast, lunch, and dinner. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with lead caregiver and a copy of this report was provided to lead caregiver. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240508134903
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4). Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility… (4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:
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Licensee to submit a plan ensuring the timely and accurate delivery of prescribed medication to residents in care. Plan to be submitted to LPA by POC due date.
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Based on record review, Licensee did not ensure R5 was assisted with prescribed medication. This posed an immediate health and safety risk to resident in care.
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Licensee to read regulation 87465(a)(4) and submit a signed declaration of understanding to LPA by POC due date.
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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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6