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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002597
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:25:48 PM

Substantiated


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
05/01/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230501103228
FACILITY NAME:ALLEN'S CARE HOME #2FACILITY NUMBER:
347002597
ADMINISTRATOR:ALLEN, MELVINAFACILITY TYPE:
735
ADDRESS:1304 MAIN AVENUETELEPHONE:
(916) 359-4319
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 4DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melvina Allen and Shawna SmithTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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The facility does not have a current administrator.
Facility is not following reporting requirements.
Staff did not provide adequate supervision resulting in resident leaving the facility.
Facility failed to provide supervision to clients in care.
Facility is not maintaining clients' P&I records.
INVESTIGATION FINDINGS:
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On 06-20-2023 at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to deliver complaint findings. LPA Martinez met with Melvina Allen and Shawna Smith and explained the purpose of today's visit.

Throughout the investigation, LPA Martinez conducted interviews; review facility files; and inspected the facility. LPA Martinez was informed the Administrator's certificate expired on February 20, 2023. It was learned the Department received Administrator Certificate renewal documentation on May 30, 2023, and the renewal process is still pending. As a result, the facility does not have a current Administrator. LPA Martinez requested the following documents for temporary Administrator: Documents Requested: LIC 503 Health Certification Form, LIC 500 Personnel Report, LIC 501 Personal Record. Documents due by June 23, 2023 by 5 PM.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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 7
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
05/01/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230501103228

FACILITY NAME:ALLEN'S CARE HOME #2FACILITY NUMBER:
347002597
ADMINISTRATOR:ALLEN, MELVINAFACILITY TYPE:
735
ADDRESS:1304 MAIN AVENUETELEPHONE:
(916) 359-4319
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 4DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melvina Allen and Shawna SmithTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
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9
Staff did not allow client to enter the facility.
Staff did not prevent resident from forcing another resident to take medication.
Facility does not have an adequate supply of food.
Facility is not adhering to their approved fire clearance.
INVESTIGATION FINDINGS:
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On 06/20/2023 at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Melvina Allen and Shawna Smith during today’s visit and explained the purpose of today’s visit.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and conducted facility inspections. During interviews, it was reported client 1 (C1) was allowed in the facility. Staff 1 (S1) reported they informed client C1 to reenter the facility while C1 was sitting at the outside facility front porch. Due to conflicting information, there is not enough evidence to substantiate this allegation. In addition, facility staff 2 (S2) reported C1 never reported C2 forced them to ingest medication. Futhermore, S2 was unaware C2 had medication stored in their room, due to privacy rights S2 is not able to search C2's room without permission. As a result, there is not sufficent evidence to prove facility staff did not provide care and supervision to C1 and C2.
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20230501103228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ALLEN'S CARE HOME #2
FACILITY NUMBER: 347002597
VISIT DATE: 06/20/2023
NARRATIVE
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Moreover, during facility inspections, LPA Martinez inspected the facility food supply, and LPA Martinez observed an adequate amount of food. In addition, S1 reported clients participate in creating food menus. Moreover, during today's visit, LPA Martinez inspected the food supply, and it was determined the facility has a sufficient amount of food. In addition, LPA reviewed fire clearance, and the facility is adhering the approved fire clearance.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20230501103228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ALLEN'S CARE HOME #2
FACILITY NUMBER: 347002597
VISIT DATE: 06/20/2023
NARRATIVE
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Furthermore, client 1 (C1) received physical abuse threats from client 2 (C2), which caused C1 to leave their room and sit outside at the facility front porch at 3:30 AM on April 26, 2023. During interviews, it was reported staff 1 (S1) was unaware of of C1 and C2 argument, and did not interven in the argument. It was learned S1 became aware of C1 and C2's argument when they witnessed C1 walking out to the facility front porch.

Moreover, S1 reported they were unaware when C1 left the facility premises. In addition, the facility did not call local law enforcement to report C1 was missing from the facility or report the physical abuse threats. Also, the facility did not submit an incident report to Community Care Licensing Department (CCLD) until April 27, 2023 at 4:34 PM.

An immediate $500.00 civil penalty shall be assessed on June 20, 2023; based on the allegation: "Staff did not provide adequate supervision resulting in resident leaving the facility." C1 was not provided adequate care supervision resulting in R1 leaving the facility at 3:30 AM on April 26, 2023, which posed an immediate threat to the Health and Safety of C1.

LPA Martinez reviewed P&I documentation on June 20, 2023 with the Licensee, Melvina Allen,. It was learned client 3 (C3) P&I documentation had discrepancies. C2 had a total of $46.96 in their P&I account, however, the P&I ledger reported C2 had $10.96. During the visit, it was unknown how much money C2 received for the month of June 2023 and how much money was spent in June of 2023.


As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20230501103228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALLEN'S CARE HOME #2
FACILITY NUMBER: 347002597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2023
Section Cited
CCR
80061(d)
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Reporting Requirements(d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four...
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Melvina Allen agrees to email LPA Martinez reporting requirements training plan by POC date 06/21/2023. Melvina Allen agrees to conduct training on reporting requirements to all staff by 06/30/2023 and all training documents will be emailed to LPA Martinez on 06/30/2023 by 5 PM.
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Welfare and Institutions Code Section.This requirement was not met as evidence by: Based on interviews and file reviews, the Licensee did not report C1 and C2 altercation with physical abuse and threats in a timely manner. This posed a potential health and safety risk to C1 and C2.
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Type B
06/23/2023
Section Cited
CCR
85064(a)(b)
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Administrator Qualifications and Duties 85064(a)(b): In addition to Section 80064, the following shall apply...All adult residential facilities shall have a certified administrator. This requirement was not met as evidence by:
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Melvina Allen has submitted Admin Cert renewal documentation to the Dept. Melvina Allen agrees to submit temporary admin documentation to LPA Martinez by POC Date 06/23/2023 by 5 PM. Documents Requested: LIC 503 Health Certification Form, LIC 500 Personnel Report,
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based on file review and interviews, the Licensee did not ensure the assigned Administrator had a current Admin Cert. This posed a potential health and safety risk to clients in care.
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LIC 501 Personal Record.
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: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20230501103228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALLEN'S CARE HOME #2
FACILITY NUMBER: 347002597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision 80078(a): the licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidence by: based on interviews, file review C1 left the facility
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Melvina Allen agrees to email LPA Martinez Care and Supervision training plan by POC date 06/21/2023. Melvina Allen agrees to conduct training on providing care and supervision to all staff by 06/30/2023 and all training documents will be emailed to LPA Martinez on 06/30/2023 by 5 PM.
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at 3:30 AM on April 26, 2023. Staff were not aware that C1 left the facility. This posed an immediate health and safety risk to C1.
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Type A
07/03/2023
Section Cited
CCR
85075.4(a)
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Observation of the Client 85075.4(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning. This requirement was not met as evidence by. Based on file review and interviews:
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Melvina Allen agrees to email LPA Martinez Observation of Client training plan by POC date 06/21/2023. Melvina Allen agrees to conduct training on Observation of Clients to all staff by 06/30/2023 and all training documents will be emailed to LPA Martinez on 06/30/2023 by 5 PM.
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facility staff did not provide observed C1 and C2 and did not intervene in C1 and C2 altercation, which led C1 to leave the facility. In addition, facility staff did not call Law Enforcement when C1 physically abused and threatened by C2. This posed an immediate health and safety risk to C1 and C2.
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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: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20230501103228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALLEN'S CARE HOME #2
FACILITY NUMBER: 347002597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
80026(h)
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80026 (h) Safeguards for Cash Resources, Personal Property, and Valuables of Residents: Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care... This requirement was not met as evidence by:
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Melvina Allen agrees to email LPA Martinez P&I training plan by POC date 06/21/2023. Melvina Allen agrees to conduct training on P&I to all staff by 06/30/2023 and all training documents will be emailed to LPA Martinez on 06/30/2023 by 5 PM.
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Based on observation and file review the Licensee did not ensure clients P&I records were maintained and in the facility for review. This posed a potential health and safety risk for clients 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: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7