347001571-10-26-2023-27-AS-KHOS-CX5Q49-20231031114958

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001571
Report Date: 10/13/2023
Date Signed: 10/26/2023 09:15:52 AM

Unsubstantiated

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
03/17/2023 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230317105207

FACILITY NAME:	RICHBOROUGH FOUNTAIN, INC.		FACILITY NUMBER:	347001571
ADMINISTRATOR:	SALVADOR, RYAN		FACILITY TYPE:	735
ADDRESS:	9038 RICHBOROUGH WAY		TELEPHONE:	(916) 685-1194
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Josephine Shobhna		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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9

Resident used illegal drugs at the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint in vestigation findings. LPA met with facility staff, and explained the purpose of th visit. LPA was later met by Facility Manager Josephine Shobna.
On 03/16/23, Resident 1 (R1) tested positive for Fentanyl. Based on medical records for 03/04/23 - 03/15/23, records do not show R1 was prescribed Fentanyl while in care. Interviews with staff members S1 - S4 revealed that all staff denied giving or providing R1 Fentanyl. Based on records review, all residents at Richborough Fountain are unable to leave unassisted. Records review show that no residents are prescribed Fentanyl. On 03/17/23, ACRC conducted an unannounced visits where they found no immediate danger to residents in care. R1 is unable to provide information regarding Fentanyl.

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(s) did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was held, and a copy of report was provided.
This report was amended to mark the report public instead of confidential

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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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