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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000175
Report Date: 01/31/2025
Date Signed: 01/31/2025 03:36:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
01/28/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250128152825
FACILITY NAME:CAJUCOM CARE HOME #1FACILITY NUMBER:
347000175
ADMINISTRATOR:EDILBERTO Z CAJUCOMFACILITY TYPE:
740
ADDRESS:3024 EASTERN AVETELEPHONE:
(916) 483-3033
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:11CENSUS: 5DATE:
01/31/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Carlo EsquilloTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not keep facility free of bed bugs.
Staff leaves residents unsupervised
INVESTIGATION FINDINGS:
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On 1-31-25 at 12:55pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the allegations noted above. LPA met with facility manager (S1) upon arrival. Administrator Edilberto Cajucom was made aware of LPAs visit and purpose and gave permission for S1 to sign in his absnece. LPA explained the purpose of the visit to S1 and Administrator. During this investigation, LPA conducted interviews with three residents and one staff member. LPA also requested facility file documentation including staffing schedule, resident roster, and pest control agreement. Additionally, LPA conducted a facility observation.

Allegation: Staff did not keep facility free of bed bugs. LPA conducted interviews, record reviews, and facility observation as noted above. Based on interviews and facility observation, it was determined that facility has current presence of bed bugs and notified pest control company for service. It was further revealed that pest control company was on site 1-30-25, however, did not treat facility. Based on interview conducted it was revealed that facility had an agreement for pest control to service facility on 1-5-25, however, pest control did not come out until 1-30-25. {Cont. on 9099C}.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
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 3
Control Number 27-AS-20250128152825
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CAJUCOM CARE HOME #1
FACILITY NUMBER: 347000175
VISIT DATE: 01/31/2025
NARRATIVE
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Interviews further revealed that facility staff did not make additional attempts to contact other pest control companies to urgently address the bed bug occurrence. During facility observation, LPA observed bed bug and evidence of bed bugs in room #3. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff leaves residents unsupervised. LPA conducted interviews, record reviews, and observation as noted above. Based on interview conducted, it was revealed that facility staff have left facility to assist another facility next door on a "frequent" basis, resulting in an absence of supervision for a period of time. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

As a result of today's investigation, citations are issued under Title 22, Division 6 An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision and violation of Section 87413(a)(1). An additional civil penalty in the amount of $250 is issued due to repeat violation of Section 87303(a). An exit interview was conducted with S1 and a copy of this report was provided. LIC 811 and appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250128152825
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CAJUCOM CARE HOME #1
FACILITY NUMBER: 347000175
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/03/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not as evidenced by:
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Licensee to conduct diligent attempt to contact various pest control companies and arrange for treatment by 2-3-25 for specific bed bug treatment. Licensee to submit proof of service arrangement and contact attempts to LPA by POC due date.
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Based on observation and interview, facility has a presence of bed bugs without evidence of adequate attempts to treat the occurrence. This poses an immediate health and safety risk to residents in care.
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Request Denied
Type A
02/03/2025
Section Cited
CCR
87413(a)(1)
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87413 Personnel-Operations. (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not as evidenced by:
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Licensee will submit a plan ensuring on-going 24/7 coverage of on-site staff at facility. Plan to be submitted tot LPA by POC due date.

Licensee to read regulation 87413(a)(1) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interviews conducted, staff have left facility unattended resulting in an absence of supervision. This posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3