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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001602
Report Date: 01/09/2024
Date Signed: 01/09/2024 10:11:21 AM

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
01/03/2024 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20240103155033
FACILITY NAME:KELLY ACACIO'S CARE HOMEFACILITY NUMBER:
347001602
ADMINISTRATOR:ACACIO, LYNDALEFACILITY TYPE:
735
ADDRESS:8333 HOLLY JILL WAYTELEPHONE:
(916) 395-9279
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 5DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Kelly AcacioTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Lack of supervision resulting in resident going AWOL.
INVESTIGATION FINDINGS:
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On 1/9/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to commence a complaint investigation with the allegation above. LPA met with Administrator Kelly Acacio and explained the purpose of the visit.

During the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and record reviews it was determined that the Licensee did not ensure that care and supervision was provided as necessary to meet R1's needs. R1 had eloped from the facility on 1/1/2024 unassisted by staff. Review of R1’s LIC 602 revealed that R1 has been determined to be unable to leave the facility unassisted by his physician. It was determined that facility was unaware of R1’s general whereabouts on 1/1/2024.

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 9099-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations.

Exit interview conducted, a copy of this report, LIC 9099-D, and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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
Control Number 27-AS-20240103155033
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: KELLY ACACIO'S CARE HOME
FACILITY NUMBER: 347001602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2024
Section Cited
CCR
80078(a)
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80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met by.
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Administrator/Licensee will provide an in-service training for all staff regarding care and supervision and submit a signed statement of understanding that licensee has read the following section 80087(a) to its entirety to LPA by POC date of 1/10/2024.
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Based on interviews and record reviews it was determined that Licensee did not ensure that care and supervision was provided as necessary to meet R1's needs. R1 AWOL’ d from the facility on 1/1/24. This poses an immediate 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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2