347004560-4-4-2023-27-AS-SRIN-CQSLLA-20230411085046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004560
Report Date: 04/04/2023
Date Signed: 04/04/2023 03:03:41 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
04/03/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230403102053

FACILITY NAME:	ST. LUKE'S RESIDENTIAL FACILITY		FACILITY NUMBER:	347004560
ADMINISTRATOR:	COLLADO, JOHNNY		FACILITY TYPE:	740
ADDRESS:	4127 RIO LINDA BLVD.		TELEPHONE:	(916) 568-9696
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95838
CAPACITY:	6	CENSUS: 1	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Cecila Collado and Johnny Collado		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is refusing take resident back after hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/4/23 at 11:30a. LPA called to request the front gate to be unlocked. LPA spoke with Johnny Collado regarding todays visit. LPA met with Celia Collado who assisted with todays visit. Johnny Collado arrived within 15 minutes to assist with todays visit. LPA mentioned the purpose of the visit.

LPA interviewed Administrator and staff #1 and Staff 2 during this visit. LPA obtained admittance from Johnny Collado who stated that the resident #1 (R1) needs a higher level of care for not allowing assistance with activities of daily living and using profanity. According to Johnny Collado, R1 wanted to see a physican to be able to walk but refused physical therapy. Johnny Collado stated to LPA during this visit that R1 can not come back to the facility because notice was given to Community Care Licensing (CCL) August 16, 2022 of the intended closure.

Substantiated

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: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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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Control Number 27-AS-20230403102053

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: ST. LUKE'S RESIDENTIAL FACILITY	FACILITY NUMBER: 347004560
	VISIT DATE: 04/04/2023

NARRATIVE

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In addition, Johnny Collado is relocating to the Philippines on April 11, 2023. The flight confirmation was shown to LPA during this visit.

Johnny Collado stated that due to health issue of Administrator, R1 is not going to be able to be taken care of properly.

Therefore, Johnny Collado refused to allow R1 to return to the facility.

There are 2 residents residing in the facility at this time. LPA was given copies of the intent to close with eviction notices to residents on August 16, 2022 that were submitted to CCL date stamped on 8/16/22.

Based on the information and admittance of the Licensee to not accept R1 back into the facility, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any 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.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230403102053

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: ST. LUKE'S RESIDENTIAL FACILITY	FACILITY NUMBER: 347004560
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2023 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	Eviction The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement is not met as evidenced by: Administrator/License did not ensure R1 was allowed to return when discharged from the hospital.	1 2 3 4 5 6 7	The Administrator/Licensee shall submit in writing that all residents when deemed necessary be given an eviction notice with pertinent information included in the notice as per Health and Safety Code and Title 22 Regulations. To be faxed by POC due date.
	8 9 10 11 12 13 14	Based on Administrator confirming resident was and continue to be not allowed to return to facility due to pending closure and an Unlawful detainer was not filed. This possess an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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