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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001880
Report Date: 07/05/2023
Date Signed: 07/05/2023 10:11:02 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
06/02/2023 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20230602104604
FACILITY NAME:ED DAVID CARE HOME #2FACILITY NUMBER:
347001880
ADMINISTRATOR:MARINA DAVIDFACILITY TYPE:
735
ADDRESS:7200 LARCHMONT DRIVETELEPHONE:
(916) 331-4775
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: 6DATE:
07/05/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator Grace WoodfordTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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9
Facility did not administer medication to resident.
INVESTIGATION FINDINGS:
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On 7/5/2023, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Grace Woodford.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
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-20230602104604
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 #2
FACILITY NUMBER: 347001880
VISIT DATE: 07/05/2023
NARRATIVE
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Facility did not administer medication to resident.
The department conducted facility observations, record review and interviews with staff and residents to investigate this complaint allegation. During interviews, it has been revealed that the facility did dispense all resident’s medications on time and administered on time. Records reviewed for May and June 2023, for all residents, it has been discovered that the facility kept a proper log for all medications in the centrally stored medication log per physician’s orders and documented in MAR without any errors. Based on this information, this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

Exit interview with Administrator. Copy of the report provided to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
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