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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700250
Report Date: 10/23/2024
Date Signed: 10/25/2024 11:06:15 AM

Substantiated


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
09/19/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240919102009
FACILITY NAME:OPTIMUM SENIOR CARE HOMEFACILITY NUMBER:
392700250
ADMINISTRATOR:PRISCILLA QUITEVISFACILITY TYPE:
740
ADDRESS:209 N SCHOOL STREETTELEPHONE:
(209) 339-9846
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:24CENSUS: 22DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Priscilla QuitevisTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 10/23/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Priscilla Quitevis.
A brief interview was conducted with the facility designated Administrator at this time.
Current census was 22 residents.
The purpose of this visit was to inform this facility, and its representative, in regards to the findings from this complaint investigation.
Based on a review of the forms and documents, it was learned that a recent pest control visit was conducted on 09/26/2024 by the contracted pest control company Zap Termite and Pest Control. The service call was completed and a report was issued to this facility at that time. It was observed that from the pest control company's visit and assessment, it was concluded that further treatment would be needed to address the presence of bed bugs. It was learned that bed bugs were discovered in the resident bedrooms, particularly in resident bedrooms (# 1, 2, 6, and 10), which would require additional treatments. It was also learned from the report that bed bugs were also found in the facility TV room as well.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 27-AS-20240919102009
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: OPTIMUM SENIOR CARE HOME
FACILITY NUMBER: 392700250
VISIT DATE: 10/23/2024
NARRATIVE
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As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240919102009
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: OPTIMUM SENIOR CARE HOME
FACILITY NUMBER: 392700250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
87303(a)
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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.
Based on records review, this facility was
found to be deficient of this section as
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The facility designated Administrator stated that a duly licensed pest control company will be contracted for services to remove and eradicate the presence of bed bugs from this facility. A statement of correction, along with a copy of the contract for services with a duly licensed pest control company, will be
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evidenced by the presence of bed bugs from a contracted pest control assessment and report conducted on 09/26/2024. This presented an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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completed and submitted into CCL by the due date.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3