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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003426
Report Date: 01/24/2024
Date Signed: 01/31/2024 03:59:37 PM

Unsubstantiated


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
07/12/2023 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20230712160817
FACILITY NAME:DEL VISTA RESIDENTIAL CAREFACILITY NUMBER:
347003426
ADMINISTRATOR:SAEL, TATY L.T.FACILITY TYPE:
740
ADDRESS:78 DEL VISTA CIRCLETELEPHONE:
(916) 690-7243
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 5DATE:
01/24/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Taty SaelTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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- Resident sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
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On 1/24/2024 at 10:15am Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to continue conducting a complaint investigation and to deliver findings for the allegations noted above. LPA Villanueva initially met with the staff on duty and explained the purpose of the visit. The Administrator, Taty Sael, was made aware of this visit and arrived shortly after. Throughout this investigation, the LPA conducted facility observation, staff interview, facility record review, staff record review, and resident record review.

Allegation: Resident sustained unexplained injuries while in care. Per interview with the administrator on 11/3/23, the administrator was informed by R1’s nurse that R1 bruises easily due to a medication. Further interviews reveal that bruising would come and go and that bruising would sometimes appear when R1 would sleep on the side. Also, during an interview with the administrator reveal that R1’s overall health started declining in November 2022.

{Con't to LIC9099...}

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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-20230712160817
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: DEL VISTA RESIDENTIAL CARE
FACILITY NUMBER: 347003426
VISIT DATE: 01/24/2024
NARRATIVE
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{...Con't from LIC9099}

R1's medication record also reviewed. Based on interview and record reviews, there is not a preponderance of evidence to conclude that R1 sustained unexplained injuries while in care. Therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Taty Sael, Administrator, and a copy of this report and appeal rights were provided
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2