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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000395
Report Date: 12/01/2023
Date Signed: 12/01/2023 04:41:36 PM

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
11/28/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20231128090036
FACILITY NAME:AGUSTIN CARE HOMEFACILITY NUMBER:
347000395
ADMINISTRATOR:AGUSTIN, MARIAFACILITY TYPE:
740
ADDRESS:9166 SEBASTIANI WAYTELEPHONE:
(916) 896-1974
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 6DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria AgustinTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not refill resident's medication in a timely manner.
INVESTIGATION FINDINGS:
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On 12/1/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation with the allegation above. LPA met with Administrator Maria Agustin and explained the purpose of the visit.

Through interview and review of records, LPA learned that resident (R1) did ran out of medication, Quetiapine, for 5 days. From review of documents and interview with staff, it appears that the facility did contact the resident's pharmacy for medication refill, however the pharmacy did not get a response from the primary doctor and the prescribing doctor from the hospital. R1’s medication, Quetiapine, ran out on 11/22/23 and facility sent resident to ER on 11/27/23. The administrator acknowledged that she has made a mistake and should have gone to ER to get the medication sooner instead of waiting on the pharmacy.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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 5
Control Number 27-AS-20231128090036
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: 12/01/2023
NARRATIVE
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Based on interviews conducted, and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit.

Exit interview held, Appeal Rights discussed, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231128090036
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not met as evidenced by:
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The Administrator will devise a plan of correction to ensure that resident medications are re-ordered in a timely manner. Plan will be submitted to CCL by 12/4/2023.
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Based on interview, the Licensee did not ensure that R1 is receiving medication in a timely manner. R1 missed 5 doses of one medication. This poses 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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/28/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20231128090036

FACILITY NAME:AGUSTIN CARE HOMEFACILITY NUMBER:
347000395
ADMINISTRATOR:AGUSTIN, MARIAFACILITY TYPE:
740
ADDRESS:9166 SEBASTIANI WAYTELEPHONE:
(916) 896-1974
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 6DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria AgustinTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
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9
Staff abandoned resident at the hospital.
INVESTIGATION FINDINGS:
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On 12/1/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation with the allegation above. LPA met with Administrator Maria Agustin and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on statements obtained, it was determined that there is not a preponderance of evidence to support that staff abandoned resident at the hospital. The Administrator stated that she has never refused to let the resident return. She reported that she asked the hospital social worker if it was possible to find resident another care home but she did not say no to accepting the resident back.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231128090036
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: 12/01/2023
NARRATIVE
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As a result of the investigation, LPA finds the allegation above 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.

Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5