347000120-6-2-2022-27-AS-CACL-CF6NCK-20220607102049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000120
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:06:23 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/16/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220516082146

FACILITY NAME:	CAJUCOM CARE HOME #2		FACILITY NUMBER:	347000120
ADMINISTRATOR:	EDILBERTO Z CAJUCOM		FACILITY TYPE:	740
ADDRESS:	3030 EASTERN AVE		TELEPHONE:	(916) 489-1771
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	12	CENSUS: 8	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lupe Cajucom		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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9

Facility has bed bugs.

INVESTIGATION FINDINGS:

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On 6-2-2022 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA met with Lupe Cajucom and explained the purpose of today's visit.

LPA Martinez toured the facility and conducted interviews. It was learned the facility has bed bugs. The facility licensee is working with a pest control company. The facility will be undergoing bed bug treatment. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations,

An exit interview was conducted with Lupe Cajucom. A copy of this 809 report, LIC 9099-D, and appeal rights were given to the facility.

An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/16/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220516082146

FACILITY NAME:	CAJUCOM CARE HOME #2		FACILITY NUMBER:	347000120
ADMINISTRATOR:	EDILBERTO Z CAJUCOM		FACILITY TYPE:	740
ADDRESS:	3030 EASTERN AVE		TELEPHONE:	(916) 489-1771
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	12	CENSUS: 8	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff cannot communicate due to language barrier.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6-2-2022 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to deliver complaint findings. LPA met with Lupe Cajucom and explained the purpose of today's visit.

LPA Martinez toured the facility and conducted interviews. During the facility visits, LPA Martinez observed residents interact with staff, and they were able to communicate efficiently. Moreover, during the facility visits, LPA Martinez was able to communicate with staff with no communication issues. Residents reported having no issues at this facility. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20220516082146

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAJUCOM CARE HOME #2	FACILITY NUMBER: 347000120
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 (a)Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met evidence by. Based on evidence the licensee did not ensure the facility did not have bed bugs.	1 2 3 4 5 6 7	Licensee will be conducting pest treatments 06/07/2022 and will follow up with LPA by POC Date 06/16/2022 in regards to clearance of bed bugs.
	8 9 10 11 12 13 14	This posed a potential health and safety 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.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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