347005228-12-29-2023-27-AS-CACL-CZ5M5D-20240103081810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005228
Report Date: 12/29/2023
Date Signed: 12/29/2023 09:21:53 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
12/18/2023 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20231218195850

FACILITY NAME:	PARK RANCH RCFE		FACILITY NUMBER:	347005228
ADMINISTRATOR:	ESTIFANIE A. TUALA		FACILITY TYPE:	740
ADDRESS:	904 PARK RANCH WAY		TELEPHONE:	(916) 400-4668
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 6	DATE:	12/29/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Lucas Manurung		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Other: Staff's conduct poses a risk to residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Park Ranch RCFE on 12/29/23 at 9:15am to conclude the investigation of the above allegations and to deliver the findings. LPA met with staff member Lucas Manurung and together discussed the investigation details.

Based on the interviews conducted and statements obtained during the investigation process, the allegations cannot be corroborated because the staff member who is alleged to have an out of state criminal activity record has never worked at this facility. Per staff interview and interviews with the licensee, both parties denied the allegation and provided statements and documentation that the identified staff member, although associated to all facilities owned by the licensee, has never worked at this location. The Administrator agreed to create a guardian account with CCLD and disassociate the staff member who never worked at the facility to ensure this type of allegation does not reoccur.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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-20231218195850

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PARK RANCH RCFE	FACILITY NUMBER: 347005228
	VISIT DATE: 12/29/2023

NARRATIVE

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The Department has investigated the complaint alleging other. 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.

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

Exit interview was conducted with the facility staff and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC9099 (FAS) - (06/04)

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