347005369-11-16-2020-27-AS-KHOS-BVFPEU-20201117101543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005369
Report Date: 11/16/2020
Date Signed: 11/16/2020 01:42:52 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
06/03/2020 and conducted by Evaluator Danyle Wolter

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200603151425

FACILITY NAME:	ALMOND HOME CARE		FACILITY NUMBER:	347005369
ADMINISTRATOR:	ROMENA, ANGELINA		FACILITY TYPE:	740
ADDRESS:	6701 ALMOND AVENUE		TELEPHONE:	(916) 817-1668
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 5	DATE:	11/16/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Angelina Romena, administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility has roaches

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wolter contacted the facility on 11/16/2020 to deliver findings for a complaint Community Care Licensing (CCL) received on 06/03/2020 via telephone due to COVID-19 and pre-cautionary measures, LPA spoke with administrator Angelina Romena and explained the purpose of the call.

Throughout the course of the investigation CCL conducted interviews with a witness (W1) and administrator regarding the complaint allegation: facility has roaches. In an interview CCL conducted with the administrator it was disclosed that the facility had had roaches for 2-3 weeks and the administrator was in the process of getting pest control to the facility.

Report continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle Wolter	TELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

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-20200603151425

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: ALMOND HOME CARE	FACILITY NUMBER: 347005369
	VISIT DATE: 11/16/2020

NARRATIVE

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Due to this information CCL finds the allegations 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.

Deficiency being cited on the attached LIC 9099-D has already been cleared, plan of correction for pest control services was received on 06/15/2020.

Exit interview conducted. A copy of the report and appeal rights were e-mailed to administrator, administrator to print and sign a copy and return to CCL either by fax, e-mail, or USPS. A signed copy should also be retained for facility records.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle Wolter	TELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200603151425

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: ALMOND HOME CARE	FACILITY NUMBER: 347005369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/16/2020 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Licensee contacted pest control services, conducted a deep cleaning of infected area, and met with residents regarding the issue. Proof of correction was received on 06/15/2020. Deficiency is cleared.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: interviews. The licensee failed to comply with the regulation referenced above. In interviews with W1 and administrator it was told to CCL that the facility had roaches. This poses a potential 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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle Wolter	TELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC9099 (FAS) - (06/04)

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