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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002861
Report Date: 06/09/2023
Date Signed: 06/09/2023 11:52:02 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2022 and conducted by Evaluator DeAnna Williams-Lyons
COMPLAINT CONTROL NUMBER: 25-AS-20221130100105
FACILITY NAME:TELECARE EL VERANOFACILITY NUMBER:
345002861
ADMINISTRATOR:MCDERMOTT, CARISSAFACILITY TYPE:
738
ADDRESS:8736 EL VERANO AVENUETELEPHONE:
(707) 815-7145
CITY:ELVERTASTATE: CAZIP CODE:
95656
CAPACITY:4CENSUS: 2DATE:
06/09/2023
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Michelle Wood, Office CoordinatorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff harassed resident
Staff did not treat resident with dignity.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On June 9, 2023, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 25-AS-20221130100105. LPA met with Michellw Wood, and explained the reason for the visit. On December 9, 2022, the department received a complaint alleging staff harassed resident and resident was not treated with dignity and respect. LPA reviewed facility documents and Office Coordinatorviewed 2 staff and the regional manager.
Regarding the allegation that staff harassed resident, LPA was not able to interview resident due to mental defect, however,LPA interviewed both staff. It was determined that staff did not harassed resident. Interviews and documents reviewed concluded that 2 staff worked the NOC shift that morning, and based on both interviews with both staff, LPA was not able to determine if staff did or did not treated resident with dignity or respect. Both allegations are UNSUBSTANSIATED.
No citations were issued. A copy of this report was given to Michelle.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
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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