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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002881
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:28:29 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, 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
07/19/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240719123419
FACILITY NAME:CARE HORIZONS ASSISTED LIVING, LLCFACILITY NUMBER:
345002881
ADMINISTRATOR:IORDACHE-STIR, ADRIANAFACILITY TYPE:
740
ADDRESS:6630 CARE LANETELEPHONE:
(916) 205-2273
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:CaregiverTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained unexplained injury in care
Facility staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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On xx/xx/xx, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Caregivers/ designees. Administrator was informed of the visit.

LPA conducted records review and interviews.
LPA is unable to find and or meet the preponderance, per policy.

On 7/26/24, LPA conducted an investigation visit, observed residents in care and conducted interviews.
R1 was interviewed and provided an explanation of an incident where they sustained a black eye that was different than her previous accounts. R1 was onserved to be treated respectfully by caregivers. R2 was unable to participate in an interview as they were asleep.
At todays visit, R1 is currently hospitalized for observation and treatment of frequent behavioral incidents. R2 has relocated to another of the licensee's care homes.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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 2
Control Number 59-AS-20240719123419
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: CARE HORIZONS ASSISTED LIVING, LLC
FACILITY NUMBER: 345002881
VISIT DATE: 09/10/2024
NARRATIVE
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Observations, interviews and records showed that R1 and R2 have issues frequently addressed by caregivers according to resident care plans.

As a result of this investigation, LPA finds allegation to be (US)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 with caregiver, Nichalet Brave.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2