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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003251
Report Date: 04/29/2025
Date Signed: 05/28/2025 02:41:33 PM

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
01/14/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250114123636
FACILITY NAME:ASTORIA GARDENSFACILITY NUMBER:
397003251
ADMINISTRATOR:OMOLE, AKINDELEFACILITY TYPE:
740
ADDRESS:1960 WEST LOWELLTELEPHONE:
(559) 313-8062
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:77CENSUS: 57DATE:
04/29/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Farial ShokoorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff do not follow infection control practices
INVESTIGATION FINDINGS:
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On 04/29/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Representative (FDR), Jessica Moreno and explained the purpose of the visit. The purpose of this visit was to delivery complaint findings for the allegation above.

Current census was 57. A brief interview with FDR Moreno was conducted. .
It was alleged that the staff did not follow infection control practices. During the course of this investigation LPA conducted interviews and records review.
Based on interviews conducted, it was determined that the facility experienced multiple infection control outbreaks in December 2024. During an interview with facility staff, it was confirmed that infection control protocols were not implemented in accordance with the facility’s regulatory standards until after the facility had identified multiple confirmed cases of scabies, influenza, and COVID-19. Interviews with nine (9) resident family members revealed that all nine (9) individuals were aware of the outbreaks occurring within the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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 27-AS-20250114123636
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: ASTORIA GARDENS
FACILITY NUMBER: 397003251
VISIT DATE: 04/29/2025
NARRATIVE
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However, each stated that they did not observe the implementation of appropriate infection control measures such as signage, use of personal protective equipment (PPE), or other preventative actions until the facility experienced continuous positive cases between October 2024 and January 2024. LPA reviewed the facility’s Infection Control Plan, dated 09/01/2024, and signed by the Facility Designated Administrator. The plan was found to be incomplete and lacking required elements. Facility management indicated that infection control protocols are to be overseen by the facility nurse; however, it was confirmed that the facility nurse was not on-site from September 2024 through January 2024, and was assisting a different facility. A interview with staff confirmed that the facility nurse was not aware that the facility had any outbreaks during this time, which was not in compliance with applicable infection control oversight requirements stated by the facility. Based on the information gathered, the facility staff did not follow infection control practices.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the Facility.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250114123636
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: ASTORIA GARDENS
FACILITY NUMBER: 397003251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2025
Section Cited
CCR
87470(a)
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87470 Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:
This is not met as evidenced by: Based on observation, interview, and record review, the facility did not ensure that infection control practices were followed.
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Licensee shall submit a new infection control plan along with a statement of correction and acknowledgement to the LPA by the POC date.
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This poses a potential health, safety, and personal rights risks to persons in care.
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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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3