<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002830
Report Date: 12/21/2023
Date Signed: 12/21/2023 01:20:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
12/18/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20231218144102
FACILITY NAME:REM CALIFORNIA, LLC - SAN JUANFACILITY NUMBER:
345002830
ADMINISTRATOR:TANNENBAUM, ROSEFACILITY TYPE:
735
ADDRESS:3831 SAN JUAN AVENUETELEPHONE:
(916) 550-0668
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:4CENSUS: 4DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rolito Intal, Administrator TIME COMPLETED:
01:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Facility operated out of ratio.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/21/23, and met with the Administrator, Rolito Intal, to open a complaint investigation and deliver findings into the allegation that facility operated out of ratio.

During today's visit, LPA obtained documentation pertinent to the investigation and conducted interviews.

On 12/17/23, the facility self reported an incident that occurred on 12/16/23. A staff member (S1) left their shift at 9:00pm even though they were scheduled to work until 9:30pm. Staff (S2) reported to the Administrator, Rolito Intal, that S1 left early. The Administrator contacted staff (S3) who was scheduled to work at 10:00pm to assist as the facility was out of ratio. S3 arrived at the care home at 9:45pm. The facility was out of ratio for 45 minutes.

***********************************************Continued on LIC9099-C****************************************************
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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 3
Control Number 59-AS-20231218144102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REM CALIFORNIA, LLC - SAN JUAN
FACILITY NUMBER: 345002830
VISIT DATE: 12/21/2023
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
The facility provided LPA with the Staff/Program Schedule indicating that a minimum ratio for a home census of four (4) is two (2) staff to four (4) individuals and two (2) staff at night. According to the Employee Punch Report for 12/16/23, S1 clocked out at 9:00pm and S2 was on shift until 10:17pm. S3 arrived at the care home at 9:45pm and worked until 5:40am. Staff (S4) was also scheduled for the night shift working 10:08pm to 6:09am.

Interviews with the Administrator and the Area Director indicated that S1 was removed from the schedule and placed on unpaid leave as of 12/17/23 pending further notice.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20231218144102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REM CALIFORNIA, LLC - SAN JUAN
FACILITY NUMBER: 345002830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2024
Section Cited
CCR
85065.5(a)(2)
1
2
3
4
5
6
7
85065.5 Day Staff-Client Ratio (a)Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met: (2) For all other clients, there shall be a staff-client ratio of no less than one direct care staff to three such clients... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility agrees to complete a statement of understanding and submit to LPA by the POC due date of 1/4/23.
8
9
10
11
12
13
14
Based on interviews and records reviewed, the facility was out of ratio on 12/16/23 for 45 minutes, which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3