347000395-2-18-2021-27-AS-KHOS-BYHM74-20210223082056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000395
Report Date: 02/18/2021
Date Signed: 02/18/2021 12:52:56 PM

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
02/04/2021 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210204143102

FACILITY NAME:	AGUSTIN CARE HOME		FACILITY NUMBER:	347000395
ADMINISTRATOR:	AGUSTIN, MARIA		FACILITY TYPE:	740
ADDRESS:	9166 SEBASTIANI WAY		TELEPHONE:	(916) 896-1974
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY:	6	CENSUS: 3	DATE:	02/18/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee/Maria Agustin Telephone Call Due to COVID-19 Precautions		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff threatened the resident.
The outlet in resident's room is sparking.
Facility has rodents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace contacted Licensee by phone to deliver findings to a complaint investigation received on 02/04/2021. Findings are being delivered by phone due to current COVID-19 precautionary measures in place.
During the course of the investigation, LPA interviewed residents, staff, victim, licensee, and facility Administrator. LPA reviewed documents including, but not limited to; Incident Report, Facility Profile, Personnel Report, Medical Records, Physician Report, Staff Records, Resident Records, and Interviews.
The first allegation that staff threatened the resident, LPA did not find any evidence to support the allegation. LPA interviewed staff, residents, and reviewed medical records of victim. LPA discovered that victim was not taking medications as prescribed by physician and the side-effects included: hallucinations, yelling or cussing, isolating behavior, and periods of depression.
Based on information obtained, the department finds the allegation to be 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.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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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Control Number 27-AS-20210204143102

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: AGUSTIN CARE HOME	FACILITY NUMBER: 347000395
	VISIT DATE: 02/18/2021

NARRATIVE

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Continued from 9099 - Page 2

The second allegation that the outlet in resident's room is sparking. LPA did not find any evidence to support the allegation. LPA conducted a physical plant inspection on 2/15/21 for every outlet in the facility. There appeared to be no electrical issues, no burn marks or blackened spots around outlets, and licensee plugged a small lamp into each outlet while LPA observed the process.
Based on information obtained, the department finds the allegation to be 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.

The third allegation that facility has rodents. LPA did not find any evidence to support the allegation. LPA conducted a physical plant inspection on 2/15/21 which included: opening cupboards, looking in every closet of residents rooms, bathrooms, garage, backyard, and walkways around the property. The house was very clean and organized throughout, no obstructions in walkways, all of the bedrooms were spotless, floors had no debris, and backyard had beautiful plants or trees surrounding the walkways.
Based on information obtained, the department finds the allegation to be 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.

An exit interview was conducted with Licensee via telephone and a copy of 9099, Appeal Rights, and 811(Confidential Names) was provided via email, an electronic email read receipt confirms receiving these documents. Licensee will sign 9099, and send back electronic email to LPA Wallace on today's date.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC9099 (FAS) - (06/04)

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