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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005860
Report Date: 10/24/2025
Date Signed: 10/24/2025 04:47:40 PM

Substantiated


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
10/02/2025 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20251002101345
FACILITY NAME:MCGREGOR HOME GARFIELDFACILITY NUMBER:
347005860
ADMINISTRATOR:CARRASCO, MARIE PAZFACILITY TYPE:
740
ADDRESS:3136 GARFIELD AVENUETELEPHONE:
(916) 692-5886
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
10/24/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:CaregiverTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
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On 10/24/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Caregiver , Qala to deliver complaint findings for the above allegation. Admin was contacted by phone and was unavailable to attend.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

LPA attempted to review records for R1 who was a resident at the facility for approx one week. Additionally, LPA interviewed the allegation with the Administrator.
Administrator stated that R1 regularly had concerns regarding their medication. In a review of R1's medications, it was found that on a least one occasion R1 was given a medication at dinner time that was precribed as bedtime. The licensee utilizes a medication administration record (MAR). The MAR showed only one staff sign-off for R1's coumadin for the week. Administrator acknowledged some communication issues between R1's physician and staff for the orders for coumadin.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
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
Control Number 59-AS-20251002101345
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: MCGREGOR HOME GARFIELD
FACILITY NUMBER: 347005860
VISIT DATE: 10/24/2025
NARRATIVE
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R1 moved from the facility and staff retraining was conducted regarding medication orders, recording in the MAR and administration/ documentation of medications.
Administrator was unable to produce the centrally stored medication record for R1 and a medication count was not conducted/ recorded when R1 was discharged.

This facility has closed with a change of ownership since the receipt of this complaint.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with designee . Copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20251002101345
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: MCGREGOR HOME GARFIELD
FACILITY NUMBER: 347005860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2025
Section Cited
CCR
87465
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Incidental Medical and Dental Care a)
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement was not met based on records and statements that found R1 did not reliably receive medications as prescribed.
This posed a potential risk.
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There has been a change of ownership.
This license is closed.
Corrective actions were taken.
This POC is cleared by this visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3