347003949-7-12-2023-27-AS-KHOS-CU4NA6-20230726101702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003949
Report Date: 07/12/2023
Date Signed: 07/12/2023 11:01:51 AM

Unfounded

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
04/18/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230418173624

FACILITY NAME:	HOLY FAMILY HOME		FACILITY NUMBER:	347003949
ADMINISTRATOR:	JACKSON, CRISINA		FACILITY TYPE:	740
ADDRESS:	1440 HOOD ROAD		TELEPHONE:	(916) 532-7078
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	6	CENSUS: 5	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Maria Gloria Dulay		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility not following resident's care plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the complaint investigation on 7/12/23 at 8:30am. LPA met with Maria Gloria Dulay, Administrator and stated the purpose of the visit. LPA reviewed interviews,documentation received such as LIC602 Physician Report, Admission agreement, Pre-placement and Appraisal/Needs documentation from resident #1(R1) facility file during this visit. Based on interviews and documentation, the investigation revealed that R1 at the time the complaint was received was independent with activities of daily living, not on a special diet nor restrictions/instructions for food items. Although, staff cut food items smaller for residents there was no physician instructions or prescriptions to do so. There was not a care plan in place regarding food or swallowing issues and R1 was not diagnosed with dementia. Based on the above mentioned information, the allegations is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations, no deficiencies were observed. Exit interview held, and a copy provided.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
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)

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