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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002979
Report Date: 09/02/2025
Date Signed: 09/02/2025 04:19:33 PM

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
02/28/2025 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20250228122129
FACILITY NAME:ONLY LOVE ELDERLY CARE HOMEFACILITY NUMBER:
345002979
ADMINISTRATOR:ALEKSANDR SHELUDCHENKOFACILITY TYPE:
740
ADDRESS:4901 MELVIN DRTELEPHONE:
(808) 228-0588
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:0CENSUS: 0DATE:
09/02/2025
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Karen Lim TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not administer residents medication
Staff are not communicating with resident's authorized representative
INVESTIGATION FINDINGS:
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On 09/02/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak attempted contact with the licensee Karen Lim via phone to deliver final findings regarding a complaint that was received on 02/28/2025. The Licensee phone number is no longer in service. The facility is now closed and has been since 06/20/2025.

During the course of the investigation, the Department conducted interviews and record review.

**Report continued on 9099-C page**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
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 59-AS-20250228122129
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: ONLY LOVE ELDERLY CARE HOME
FACILITY NUMBER: 345002979
VISIT DATE: 09/02/2025
NARRATIVE
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Staff did not administer residents medication- Unsubstantiated

Resident #1 (R1) was on Hospice and prescribed and administered morphine on an as needed basis. An interview with S1 indicated they were giving R1 their medication as prescribed however stated they failed to document R1’s morphine administration. Due to insufficient documentation, the department is unable to determine is R1 was administered medications as prescribed.

Staff are not communicating with resident's authorized representative- Unsubstantiated

Based on interviews, facility staff kept R1’s authorized representative updated on R1. During the course of this investigation the department interviewed multiple individuals and was provided with conflicting information regarding if R1’s authorized representative was kept updated on R1. LPA cannot prove or disprove if communication was happening between the facility and R1s authorized representative based on the different version of events.  

Based on this information, these allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

This report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Sacramento North Regional office.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC9099 (FAS) - (06/04)
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