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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001880
Report Date: 08/03/2023
Date Signed: 08/03/2023 11:39:32 AM

Substantiated


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
05/31/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20230531143619
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:
08/03/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Marta Blanco TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff was inappropriate with clients in care.
Facility failed to report incidents to CCL.
Facility administrator is not meeting mandated reporting requirements.
INVESTIGATION FINDINGS:
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On 8/3/2023, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Marta Blanco.

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**
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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 6
Control Number 59-AS-20230531143619
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: 08/03/2023
NARRATIVE
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**Report continued from LIC9099**
Allegation- Staff was inappropriate with clients in care.
The department conducted facility observations, record review and interviews with staff and residents to investigate this complaint allegation. Based on the records reviewed, it has been determined that S1 made inappropriate remarks to facility resident, R1 on 05/15/23 in the morning when R1 was present in facility kitchen and was getting ready to go to day program. Facility staff S2 heard the inappropriate comment made by S1 to R1. During interviews, R1 confirmed this allegation and verbalized that they did not like what happened that day. Facility did their internal investigation and S1 does not work at the facility any more after that incident. Based on the investigation, it has been concluded that the allegation ‘staff was inappropriate with clients in care’ was found to be SUBSTANIATED.
Allegation- Facility failed to report incidents to CCL.
The department conducted a record review and interviews with staff and residents to investigate this complaint allegation. Based on the records reviewed, it has been determined that the facility did not report an ‘reportable incident’ where staff, S1 made inappropriate remarks to facility resident, R1 on 05/15/23. The facility should have reported this incident to CCL by 05/16/23 as required by Title 22, Regulation-80061 but facility reported this incident to CCL on 06/01/23 which was out of compliance. Based on the investigation, it has been concluded that the allegation ‘facility failed to report incidents to CCL’ was found to be SUBSTANIATED.
Allegation- Facility administrator is not meeting mandated reporting requirements.
The department conducted a record review and interviews with staff and residents to investigate this complaint allegation. Based on the records reviewed, it has been determined that the facility did not report an ‘reportable incident’ where staff, S1 made inappropriate remarks to facility resident, R1 on 05/15/23. The facility should have reported this incident to CCL by 05/16/23 as required by title 22, regulation-80061 but facility reported this incident to CCL on 06/01/23 which was out of compliance. Based on the investigation, it has been concluded that facility staff notified regarding this incident to administrator on 05/17/23 but administrator did not comply with mandatory reporter requirements and did not notify CCL till 06/01/23 as required by Title 22 Regulation-80064, therefore the allegation’ Facility administrator is not meeting mandated reporting requirements’ was found to be SUBSTANIATED.
Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above all allegations is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8,deficiencies are being cited on the attached 9099-D page.
Exit interview conducted. Appeal Rights and copy of this report has been provided to facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
05/31/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20230531143619

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:
08/03/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Marta Blanco TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility is falsifying documentation.
Facility management interrogated client regarding incident that occurred at the care home.
Facility staff mismanaging client’s medications.
INVESTIGATION FINDINGS:
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On 8/3/2023, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Marta Blanco.

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: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20230531143619
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: 08/03/2023
NARRATIVE
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**Report continued from 9099**

Allegation- Facility is falsifying documentation.
Based on the information provided, the investigation conducted by the Licensing Program Analyst (LPA) did not find any evidence to substantiate the allegation of facility staff falsifying documentation. All six staff members who were interviewed denied being instructed to change or alter resident documentation, and none of them reported hearing about such instructions being given to other staff members. Additionally, a review of the records indicated that the facility was maintaining proper documentation of residents without any indications of alteration or falsification. Based on these findings, the LPA concluded that there is not enough evidence to support the allegation, and the findings are considered unsubstantiated.
Allegation- Facility management interrogated client regarding incident that occurred at the care home. The department conducted facility observations, record review and interviews with staff and residents to investigate this complaint allegation. From the interviews with staff and residents, it has been revealed that the facility conducted their own internal investigation after S1 showed inappropriate behavior to R1 at facility on 05/15/23 to collect relevant information regarding the incident. Interviews with R1 and other residents indicated that facility did not interrogate any resident’s and asked only appropriate questions related to the incident which happened on 05/15/23. Resident interviews indicated that they were feeling safe at facility and did not express any concerns, therefore, this allegation is UNSUBSTANIATED.
Allegation- Facility staff mismanaging client’s medications.
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 been administered on time. Records reviewed for May and June 2023 for all residents, it has been discovered that the facility kept proper logs for all medications in centrally stored medication log per physician’s orders and documented in MAR without any errors. Furthermore, residents’ interviews indicated that the facility was administering residents’ medications without any issues and did not express any concerns. Based on this information, this allegation is UNSUBSTANIATED.
Based on this information, all these allegations are 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 conducted with Administrator. Copy of the report provided to facility.

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

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20230531143619
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
80072(a)(1)
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80072(a)(1)-Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons. this requirement is not met as evidence by:
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Licensee/Administrator agreed to submit a self-certification of understanding the regulation ,80072 (a)(1) and will train all staff regarding this regulation and submit proof to LPA by POC date- 08/04/23.
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Based on interviews, record review, it has been concluded that staff (S1) made inappropriate remarks to facility resident, R1 on 05/15/23 which poses immediate health and safety risks to residents in care.
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Type A
08/04/2023
Section Cited
CCR
80061(b)(F)
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80061(b)(F)--Reporting Requirements-upon the occurrence, during the operation of the facility, of any of the events ....(F)Any suspected psychological abuse of any client...this requirement is not as evidence by:
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Licensee/Administrator agreed to submit a self-certification of understanding the regulation ,80061 (b)(F) and will train all staff regarding this regulation and submit proof to LPA by POC date- 08/04/23.
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Based on interviews, record review, it has been concluded that facility did not report a incident where staff (S1) made inappropriate remarks to facility resident, R1 on 05/15/23 to department in timely way which poses immediate health and safety risks 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: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230531143619
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
80064(a)(3)
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80064-Administrator - Qualifications and Duties-(a)The administrator shall have the following qualifications:(3)Knowledge of and ability to comply with applicable law and regulation...this requiement is not met as evidence by:
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Administrator agreed to submit a self-certification of understanding the regulation ,80064 (a)(3) and will make sure to report any reportable incidents to CCL in timely way and submit proof to LPA by POC date- 08/04/23.
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Based on interviews, record review, it has been concluded that administrator did not report a incident where staff (S1) made inappropriate remarks to facility resident, R1 on 05/15/23 to department in timely way which poses immediate health and safety risks 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: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6