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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003949
Report Date: 10/14/2021
Date Signed: 10/14/2021 01:48:42 PM



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
09/27/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210927140546
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: 6DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Crisina Jackson TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
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9
Staff mismanages resident's medications.
Staff did not administer resident's medication as prescribed.
Resident did not receive a copy of the admission agreement.
INVESTIGATION FINDINGS:
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5
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On 10-14-2021 at 1:25 PM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Crisina Jackson and explained the purpose of today's visit.

During the course of the investigation, it was determined the above allegations were unfounded. Tenant 1 (T1) room and board contract was obtained during the investigation. The room and board contract states, "Crisina Jackson shall provide room and board to the renter (T1) at 1440 Hood Road, Sacramento CA, 95825...with 3 meals a day. Room and Board shall not include care and supervision." In addition, the rental room and board contract was signed by T1. As a result, of the signed and agreed upon room and board contract, an admission agreement and administration of medication will not be provided to T1.

Continued...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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 6
Control Number 27-AS-20210927140546
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: 10/14/2021
NARRATIVE
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This agency has investigated the complaint alleging: Staff mismanages resident's medications; Staff did not administer resident's medication as prescribed; and Resident did not receive a copy of the admission agreement. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
09/27/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210927140546

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: 6DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Crisina Jackson TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff speak inappropriately to residents.
Facility does not provide residents with nutritious meals.
Facility does not have a disaster plan.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10-14-2021 at 1:25 PM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Crisina Jackson and explained the purpose of today's visit.

Throughout the investigation, LPA Martinez obtained facility records and conducted interviews. LPA Martinez interviewed 5 out of 6 residents. 4 residents reported being satisfied with the care they receiving by the care staff. The 4 residents reported no staff has spoken to them inappropriately. The 4 residents reported not to have any complaints or issues against this facility. 4 Residents reported the facility was serving satisfactory meals, which were also nutritional. LPA Martinez also obtained August and September 2021 meal calendars. According to the meal calendars, the meals that were served to residents were nutritional. LPA Martinez also observed the facility food supply, there was an adequate food supply. In addition, the food supply was nutritional.

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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 6
Control Number 27-AS-20210927140546
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: 10/14/2021
NARRATIVE
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LPA Martinez observed an LIC 610E Emergency Disaster Plan For Residential Care Facilities for the Elderly at this facility. LPA Martinez observed this LIC 610E posted at the hallway wall adjacent to the main indoor activity area and kitchen area. The licensee will also update the LIC 610E to the current LIC610E (3/19) version.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/27/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210927140546

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: 6DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Crisina Jackson TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is operating over capacity.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10-14-2021 at 1:25 PM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Crisina Jackson and explained the purpose of today's visit.

During the complaint investigation, LPA Martinez toured the facility with Crisina Jackson. In addition, LPA Martinez reviewed the approved Community Care Licensing Department (CCLD) facility sketch with Crisina Jackson. LPA Martinez learned the following: The facility sketch does not reflect the current resident room layout of the facility. The facility sketch states rooms 4 and 5 are designated for staff use. However, rooms 4 and 5 are currently occupied by residents. Additionally, room 9 is designated for resident use although room 9 is being rented as room and board occupancy. Moreover, room 1 is designated for office use although it is currently being rented as a room and board occupancy. Live in staff is residing in room 8, which is designated as resident room.

Continued...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20210927140546
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: 10/14/2021
NARRATIVE
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Furthermore, The facility is at full capacity, which the facility is licensed for 6 residents. In addition, the facility licensee has rented two resident rooms as room and board occupancy. There are currently to room and board tenants residing in the facility. As a result, the facility is operating over capacity.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited on the LIC 9099-D, per Title 22 Regulations. On 09/29/2021 during a case management visit, the facility was cited 87204 (a) Limitations - Capacity and Ambulatory Status. A plan of correction (POC) for this violation was discussed with Crisina Jackson. Crisina Jackson is currently working on the POC; therefore, a second citation was not given at today's visit.

An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6