347003426-1-31-2024-27-AS-KHOS-D26T36-20240205132148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003426
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:01:16 PM

Unfounded

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 CARE		FACILITY NUMBER:	347003426
ADMINISTRATOR:	SAEL, TATY L.T.		FACILITY TYPE:	740
ADDRESS:	78 DEL VISTA CIRCLE		TELEPHONE:	(916) 690-7243
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Taty Sael		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable death.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 1/31/24, at 3/15pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to amend the report from the visit on 1/24/2024. LPA met with staff on duty and explained the purpose of the visit. The administrator, Taty Sael, was notified and arrived shortly after.

Allegation: Questionable death. The department investigated the questionable death allegation and discovered that R1's cause of death was listed on R1's discharge summary from the hospital as severe sepsis with septic shock and community acquired pneumonia. Per statement of a clerk reveals that there was no foul play or trauma relating to R1’s death. The department has found that the allegation of questionable death is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Taty Sael, Administrator, and a copy of this report and appeal rights were provided

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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