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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003775
Report Date: 07/12/2023
Date Signed: 07/12/2023 03:24:13 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
04/27/2023 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20230427152902
FACILITY NAME:LP NUNEZ CARE FACILITY #2FACILITY NUMBER:
347003775
ADMINISTRATOR:NUNEZ, LIONELFACILITY TYPE:
735
ADDRESS:9374 LOS TORRES DRTELEPHONE:
(916) 685-7759
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 3DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lionel Nunez TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not report incident to CCL or Alta Regional Center
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/12/23 at 12:30p to conclude the investigation of the above mentioned allegation. LPA met with Caregiver Edna Villanueva who contacted the Administrator regarding the purpose of todays visit. Administrator arrived within 15 minutes. LPA reviewed interviews, resident #1 (R1) facility file, Patient Clinical summary, Individual Program Plan (IPP), facility notes, staff first aid training certificates, and email from Administrator to Regional Center (RC) submitting a Shared Information Report. Regarding allegation, Facility did not report incident to CCL or Alta Regional Center, LPA observed that staff did not submit a timely incident report to Community Care Licensing (CCL) or RC. Although a shared information report was submitted to RC later the evening of 3/9/23 an incident report was not submitted to CCL.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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 5
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
04/27/2023 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20230427152902

FACILITY NAME:LP NUNEZ CARE FACILITY #2FACILITY NUMBER:
347003775
ADMINISTRATOR:NUNEZ, LIONELFACILITY TYPE:
735
ADDRESS:9374 LOS TORRES DRTELEPHONE:
(916) 685-7759
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 3DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lionel Nunez TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Facility did not ensure resident received appropriate medical treatment
Facility did not protect residents in care from harm
INVESTIGATION FINDINGS:
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13
Regarding allegation, Facility did not ensure resident received appropriate medical treatment, LPA observed that during the incident, the staff did not notice any bruising or blood on R1. After R1 left the facility, the day program noticed first aid was required and contacted the Administrator. The Administrator picked up resident, had a meeting with Regional Center, Conservator and Family. After the meeting, Administrator took resident to urgent care. The Licensed Skilled Professional deemed the bruise on the thumb needed time to heal and to be trimmed. The Licensed Skilled Professional also deemed that R1 had back pain and that neither warranted xrays. A pain medication, Tylenol was prescribed.

Regarding allegation, Facility did not protect residents in care from harm, LPA observed that facility staff was not aware that R1 was actually harmed during the incident. The bruise was discovered later after R1 went to day program at which time first aid was administered.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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 5
Control Number 27-AS-20230427152902
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: LP NUNEZ CARE FACILITY #2
FACILITY NUMBER: 347003775
VISIT DATE: 07/12/2023
NARRATIVE
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Allegation is deemed UNSUBSTANTIATED.

A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies cited.

An exit interview was conducted, copy of report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230427152902
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: LP NUNEZ CARE FACILITY #2
FACILITY NUMBER: 347003775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
80061(b)(1)(E)
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Upon the occurrence, during the operation of the facility, of any of the events...shall be made to the licensing agency within the agency's next working day...a written report...shall be submitted to the licensing agency within seven days following the occurrence of such event.
Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
(1) Events reported shall include the following:
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Licensee/Administrator shall submit in writing that all reporting requirements will be followed at all times. Fax POC by stated due date.
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This requirement is not met as evidenced by: Based on Confirmation from Administrator only a shared information report was submitted to RC. He failed to submit an SIR to CCL and RC timely.
This poses a potential health and safety risk 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: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230427152902
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: LP NUNEZ CARE FACILITY #2
FACILITY NUMBER: 347003775
VISIT DATE: 07/12/2023
NARRATIVE
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Based on confirmation of the Administrator that this did not occur, the above allegation(s) is found to be SUBSTANTIATED.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5