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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701325
Report Date: 04/09/2025
Date Signed: 07/18/2025 04:39:23 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
03/21/2025 and conducted by Evaluator Sommer Hayes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250321131446
FACILITY NAME:CHERISHED CARE HOME LLCFACILITY NUMBER:
342701325
ADMINISTRATOR:OMATSEYE, TOGHARANROSE ADAFACILITY TYPE:
735
ADDRESS:9268 CHAROLAIS WAYTELEPHONE:
(916) 868-2112
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 3DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not administer medication to a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sommer Hayes and Kimberly Viarella arrived to continue the investigation of the above-mentioned allegation on April 9, 2025. LPAs introduced themselves and stated the purpose of the visit. The Designated Facility Administrator was not available, and LPAs met the Designee, Chinenye Obiago. They arrived shortly after LPAs arrival.

This investigation consisted of interviews and record review. Interviews were conducted with resident (R1), one staff member (S1) and the designee, Chinenye Obiago. LPAs reviewed an incident report to Alta Regional Center dated 03/13/25, a copy of an email from R1 to their RP dated 03/12/25, medication records for R1 dated 01/01/24-04/09/25, ongoing notes/care notes for R1 dated 03/01/25-03/17/25.
An interview with Chinenye Obiago stated that 03/07/25, in evening, the staff noticed that R1 was out of their medication. Since it was the evening the responsible party (RP) of R1 was notified the next day on 03/08/25. Medication was ordered on 03/08/25, by R1’s RP. The medical administration record revealed R1 did not receive medication for 11 doses. On 03/13/25 at 6:00pm R1 was exhibiting a change in condition and demonstrating aggressive behaviors. Administrator,Toghararanrosae Omatseye called Elk Grove Police Department and R1 was taken to the hospital for evaluation. R1 was discharged on 03/15/25.

The preponderance of evidence standard has been met; therefore, the above allegation(s) are found to be SUBSTANTIATED.

During this investigation, LPAs learned the following:

The facility did not report the incident to Community Care Licensing as required.
The facility did not obtain an LIC 602 for R1 prior to admission which was also required.

Both of these deficiencies will be addressed in a case management at a later date.

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 report and their appeal 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:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Sommer Hayes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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-20250321131446
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: CHERISHED CARE HOME LLC
FACILITY NUMBER: 342701325
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
Section Cited
CCR
85075(b)
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Health Related Services 85075 (b)
The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
The licensee did not ensure the above regulation was met as evidence by:
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Licensee Designee stated that they will email the following information: One staff will be tracking medications and ordering two weeks in advance. If ordering is not an option facility will walk into the pharmacy to refill medicine ensuring residents do not miss any doses.
RP has given facility written permission to pickup and order medications.
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Based on interviews and a review of records R1 was not administered their medication for 11 doses which posed an immediate threat to residents in care.
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Email or fax to Community Care Licensing.
Documents may also be emailed to: CCLASCPSacramentoRO@dss.ca.gov
Fax: (916) 263-4744
This will be completed by the close of business on 04/10/2025.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Sommer Hayes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
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