347004963-3-23-2023-59-AS-KHOS-CQDKFF-20230329075152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004963
Report Date: 03/23/2023
Date Signed: 03/23/2023 12:42:29 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, 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
03/16/2023 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230316083952

FACILITY NAME:	MILES MANOR		FACILITY NUMBER:	347004963
ADMINISTRATOR:	MILES, RACHEL		FACILITY TYPE:	740
ADDRESS:	4301 WATKINS DRIVE		TELEPHONE:	(916) 967-9049
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	15	CENSUS: 13	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Kimberly Rosa, Administrator		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Facility staff are not ensuring that resident receives proper medical attention.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Kimberly Rosa, to open a complaint investigation into the allegation listed above.

Complaint received by department indicated a resident's Power of Attorney (POA) as the suspected abuser and not the facility. Allegation listed in complaint did not implicate facility. LPA will cross report complaint to Adult Protective Services (APS)

Based on records reviewed, the above allegation is found to be 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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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