342701248-12-6-2023-27-AS-KHOS-CYEJP5-20231211061300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701248
Report Date: 12/06/2023
Date Signed: 12/06/2023 11:55:03 AM

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
11/06/2023 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20231106165238

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:	12/06/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Misivono Qadroka		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident was left in soiled garments for an extended length of time
Staff did not ensure resident hygiene needs were met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced facility visit to complete and deliver findings for a complaint investigation received on 11/6/23. LPA met with Staff Misivono Qadroka and discussed the conclusion for complaint and the findings.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on resident interviews, resident (R2) and (R3) corroborated that staff (S2) had left R3 in soiled garments overnight. R3 reported that they needed to be changed, but S2 ignored and didn’t change R3 until the next morning.
Based on interviews conducted during the course of this investigation, it was learned that residents’ hygiene needs were not being met. It was learned that showers were not being provided to resident (R1) as R1 appeared dirty. It was learned that S2 didn’t know when the last time residents were showered.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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 5

Control Number 27-AS-20231106165238

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: 12/06/2023

NARRATIVE

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As a result of this investigation, the Department finds the allegations above to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20231106165238

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: 12/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/07/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, ... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall submit a plan of correction to LPA on how the facility will be in compliance with regulation 87468.1(a)(3) at all times by POC due date 12/7/2023.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the regulation cited above. R3 was left in soiled garments overnight. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 12/13/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464. Basic Services. (f) Basic services shall at a minimum include… (1) Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee shall submit a plan of correction to LPA on how the facility will ensure that residents' hygiene needs are met by POC due date 12/13/23.
	8 9 10 11 12 13 14	Based on interviews and records review, the Licensee did not ensure resident's hygiene needs are met. Staff did not provide showers to R1. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
11/06/2023 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20231106165238

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:	12/06/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Misivono Qadroka		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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9

Staff forced resident to take medications
Staff member pushed resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced facility visit to complete and deliver findings for a complaint investigation received on 11/6/23. LPA met with Staff Misivono Qadroka and discussed the conclusion for complaint and the findings.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews conducted, there is not a preponderance of evidence to support the allegations mentioned above. Based on resident interviews, resident (R1) was unable to provide any information regarding the allegations. LPA interviewed staff (S2), S2 denied forcing any residents to take medication or have pushed any residents.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20231106165238

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: 12/06/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	As a result of the investigation, the Department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5