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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003949
Report Date: 12/01/2023
Date Signed: 12/01/2023 10:42:40 AM

Unsubstantiated


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
07/17/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230717085747
FACILITY NAME:HOLY FAMILY HOMEFACILITY NUMBER:
347003949
ADMINISTRATOR:JACKSON, CRISINAFACILITY TYPE:
740
ADDRESS:1440 HOOD ROADTELEPHONE:
(916) 532-7078
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 4DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gloria DulayTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights: Facility not following care plan.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Holy Family Home on 12/1/23 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. LPA Gould reviewed resident records and records of communications with facility and Resident's authorized representatives. LPA reviewed resident records and obtained no records of physician orders for physical therapies. Staff interviews revealed that staff member did attempt to encourage resident to do exercises and documentation of attempts and resident refusals were documented. Staff interviews revealed resident was more amenable to completing exercises with daughter but would refuse and state he is tired when asked to by staff members. Interview with Ombudsman indicates again there was not a physician order and that a family friend was supporting resident's exercise regime.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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 4
Control Number 27-AS-20230717085747
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: HOLY FAMILY HOME
FACILITY NUMBER: 347003949
VISIT DATE: 12/01/2023
NARRATIVE
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Communications with facility and resident's authorized representatives also display a disconnect in understanding requirements for care in a licensed facility and requirements the facility need to initiate services such as medications and physical therapies. As this was the first placement in a licensed facility for the resident it is not unreasonable that there were expectations from a private setting that could not be met in a licensed facility such as providing over the counter medications without a physician's order. Interviews with three staff members support the findings as all staff provided statements of attempting to meet resident needs but resident would refuse services or refuse to partake in services.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/17/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230717085747

FACILITY NAME:HOLY FAMILY HOMEFACILITY NUMBER:
347003949
ADMINISTRATOR:JACKSON, CRISINAFACILITY TYPE:
740
ADDRESS:1440 HOOD ROADTELEPHONE:
(916) 532-7078
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 4DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gloria DulayTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Eviction/Discharge: Illegal Eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Holy Family Home on 12/1/23 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews conducted and statements obtained during the investigation process, the allegations cannot be corroborated because RP confirmed to LPA that they did not provide payment for board and care within the required time frame of regulations (10 days from due date) and was served with the eviction notice on 7/11/23. The eviction notice met all requirements under title 22 regulations.

The Department has investigated the complaint alleging Eviction/Discharge. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230717085747
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: HOLY FAMILY HOME
FACILITY NUMBER: 347003949
VISIT DATE: 12/01/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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28
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30
31
32
There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4