347004411-8-16-2023-59-AS-KHOS-CUSJDM-20230817065746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004411
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:46:18 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
08/07/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230807151528

FACILITY NAME:	AGAPE HOME CARE		FACILITY NUMBER:	347004411
ADMINISTRATOR:	IOSIF SAMUSI		FACILITY TYPE:	740
ADDRESS:	7551 STONE RIDGE WAY		TELEPHONE:	(916) 745-4659
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	6	CENSUS: 2	DATE:	08/16/2023
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Administrator: Daniela Samusi		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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- Staff refuse to provide resident with an assistive device prescribed by a physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 08/16/2023 to deliver complaint finding. LPA met with administrator, Daniela Samusi, and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed pertinent documentation such as, resident’s (R1) physician’s report, admission agreement, and preplacement appraisal. Interview statement received from R1 indicated, R1 does not have a doctor's orders for transfer pole. Interview statement received from staff (S1) indicated, the facility recommended an alternative method for R1.

The allegations are UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
08/07/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230807151528

FACILITY NAME:	AGAPE HOME CARE		FACILITY NUMBER:	347004411
ADMINISTRATOR:	IOSIF SAMUSI		FACILITY TYPE:	740
ADDRESS:	7551 STONE RIDGE WAY		TELEPHONE:	(916) 745-4659
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	6	CENSUS: 2	DATE:	08/16/2023
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Administrator: Daniela Samusi		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not assist resident with mobility needs in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 08/16/2023 to deliver complaint finding. LPA met with administrator, Daniela Samusi, and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed pertinent documentation such as, resident’s (R1) physician’s report, admission agreement, and preplacement appraisal. According to complainant, R1 has incontinence and needs the transfer pole to be able to get up from bed on their own to avoid having an accident, since facility staff are not always available to help R1 to the bathroom when needed.The Department received and reviewed R1's physician's report. R1's physician's report was completed on 4/21/2023. According to R1's physician's report, R1 is not able to bathe self and dress/groom self. R1 can care for own toileting needs.

Continue on page LIC-9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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 3

Control Number 59-AS-20230807151528

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AGAPE HOME CARE	FACILITY NUMBER: 347004411
	VISIT DATE: 08/16/2023

NARRATIVE

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The Department interviewed a total of three (3) facility staff. Interview statement received from S1 indicated, R1 needs assistance with bathing, toileting, and transfers. Staff indicated R1 is able to communicate their needs. S1 stated the residents at the facility are able to walk or use their wheelchairs. Resident can ask for assistance at anytime. S1 indicated, staff often checks on residents and conduct rounds after every meals. S1 indicated there was no doctor's orders for the transfer pole and the facility recommended another alternative that may help R1 with transfers. S1 stated if the transfer pole was installed they were unsure if the ceiling would be able to bare the weight. Interview statement received from S2 indicated, R1 is independent and S2 assist R1 with activities of daily living. S2 stated if S2 is unavailable to assist R1, there is always staff at the facility to assist R1 when needed.

Interview statement received from R1 indicated, R1 is independent and often request to use the bathroom on their own. R1 stated when R1 moved into the facility staff were closely monitoring R1 in the bathroom, but R1 felt uncomfortable and requested to use the bathroom on their own. R1 stated R1 would like to be independent as much as possible. R1 stated staff would conduct rounds about every 2 hours. R1 indicated, R1 does not have a doctor's order for a transfer pole. R1 stated R1's physical therapist had recommended a transfer pole, but did not receive a written order. R1 stated the transfer pole was delivered to the facility on 7/19/2023, but the facility did not install it due to liability issues and citing that the pole may ruin the ceiling.

The Department could not find enough evidence to confirm nor deny this allegation happened. The Department finds this allegation to be UNSUBSTANTIATED - meaning 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.

No deficiencies being cited for today’s visit.

Exit interview conducted and report left at the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

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