345003004-2-22-2024-59-AS-MSEY-D34T9W-20240306133238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345003004
Report Date: 02/22/2024
Date Signed: 02/22/2024 04:25:22 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
02/20/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240220102745

FACILITY NAME:	LITTLE BROOK CARE HOME		FACILITY NUMBER:	345003004
ADMINISTRATOR:	POP, PERSIDA		FACILITY TYPE:	740
ADDRESS:	8832 FAIR OAKS BLVD		TELEPHONE:	(408) 218-5197
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 5	DATE:	02/22/2024
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Persida Pop, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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-Staff placed locks on the resident's door that violates the facility fire clearance
-Staff did not ensure the facility had a working telephone

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home unannounced today, 2/22/24, and met with the Administrator, Persida Pop, to open a complaint and deliver complaint investigation findings regarding the above stated allegations.

During today's visit, LPA tested the facility phone and observed all the doors in the facility. The facility has an operable phone line for residents' use. None of the facility doors prevent residents from exiting their bedrooms or the care home.

Based on observation, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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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