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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000407
Report Date: 01/03/2023
Date Signed: 01/03/2023 11:19:47 AM

Unfounded


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
12/28/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221228095128
FACILITY NAME:CYON SAMALA FAMILY CARE HOME #2FACILITY NUMBER:
347000407
ADMINISTRATOR:SAMALA, ASUNCION CJ.FACILITY TYPE:
740
ADDRESS:1547 BELL STREETTELEPHONE:
(916) 929-9699
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 6DATE:
01/03/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:H.C SamalaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Facility is prohibiting visitors
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/3/23 at 9:45AM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Administrator H.C Samala and explained the purpose of today's visit.

Regarding the allegation of Facility is prohibiting visitors, the Department found the following; based on interview and observation, it was determined that Resident 1 (R1) did not want to have visitors. Administrator did inform family that R1 did not want to see them, facetime, or talk on the phone.

The department has investigated the above allegation and has determined that it is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit Interview was conducted, and a copy of this report was provided to the facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
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 2
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
12/28/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221228095128

FACILITY NAME:CYON SAMALA FAMILY CARE HOME #2FACILITY NUMBER:
347000407
ADMINISTRATOR:SAMALA, ASUNCION CJ.FACILITY TYPE:
740
ADDRESS:1547 BELL STREETTELEPHONE:
(916) 929-9699
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 6DATE:
01/03/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:H.C SamalaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff are not answering facility phone
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/3/23 at 9:45AM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Administrator H.C Samala and explained the purpose of today's visit.

Regarding the allegation of Staff are not answering facility phone, the Department found the following; based on interview it was determined that the facility does answer the phone when it rings. Resident 1's (R1) family has the facility phone number and administrator cell phone number. LPA called the facility number and heard the phone ring, so the facility phone does work.

Based on interviews, it is determined that the preponderance of evidence standard is not met, therefore these allegations are UNSUBSTANTIATED. A finding of 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 conducted. A copy of this report was left upon exit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
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 2