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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001879
Report Date: 07/05/2023
Date Signed: 07/05/2023 11:03:43 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/12/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20230612123731
FACILITY NAME:ED DAVID CARE HOME #1FACILITY NUMBER:
347001879
ADMINISTRATOR:MARINA DAVIDFACILITY TYPE:
735
ADDRESS:7125 CANAVERAL WAYTELEPHONE:
(916) 332-2218
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: 6DATE:
07/05/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Nene Collins TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not properly document the MAR.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 07/05/23 to deliver complaint findings for above allegations. LPA met with administrator, Nene Collins and explained the purpose of the visit. LPA wore the following Personal Protective Equipment (PPE) during today's visit-surgical mask.


The department conducted records review ,facility observations and interviews to investigate the complaint.



**Report continued on LIC9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
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
Control Number 59-AS-20230612123731
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ED DAVID CARE HOME #1
FACILITY NUMBER: 347001879
VISIT DATE: 07/05/2023
NARRATIVE
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***report continued from LIC9099...........



Allegation- Staff did not properly document the MAR.

Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled.

Furthermore, a review of the records for the months of May and June 2023 indicated that the facility maintained a proper log for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Based on these findings, the allegation’ Staff did not properly document in MAR’ is considered unsubstantiated.


A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No citations were issued today. Exit meeting conducted with administrator.
A copy of this report has been provided to facility.



SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2