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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700517
Report Date: 04/22/2024
Date Signed: 04/22/2024 03:01:51 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
12/14/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20231214111302
FACILITY NAME:KIND CARE HOME IIFACILITY NUMBER:
502700517
ADMINISTRATOR:KAHLON, HARDEEPFACILITY TYPE:
740
ADDRESS:1020 JAYHAWK WAYTELEPHONE:
(209) 523-0124
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY:6CENSUS: 5DATE:
04/22/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Kash KaurTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure that facility bathroom was sanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Jason Lund arrived unannounced to complete a complaint investigation. LPA met by Administrator Kash Kaur and explained the reason for the visit. Census:5
Staff did not ensure that facility bathroom was sanitary: LPA Lund observed the facility bathrooms, interviewed reporting party and staff. On 12/21/2023 LPA Lund observed all three bathrooms for residents in care not to be sanitary.
Based on LPA Lund observations and interview with reporting party and staff, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
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 4
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
12/14/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20231214111302

FACILITY NAME:KIND CARE HOME IIFACILITY NUMBER:
502700517
ADMINISTRATOR:KAHLON, HARDEEPFACILITY TYPE:
740
ADDRESS:1020 JAYHAWK WAYTELEPHONE:
(209) 523-0124
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY:6CENSUS: 5DATE:
04/22/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Kash KaurTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are exposing resident(s) to harmful chemicals

Staff did not assist resident with their cleaning needs

Facility refrigerator is in disrepair
INVESTIGATION FINDINGS:
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Staff are exposing resident(s) to harmful chemicals- LPA Lund interviewed reporting party, staff, residents, witnesses, LPA Lund’s observation and facility records review. LPA didn’t observe any harmful chemicals out during visits on 12/21/2023 and 4/22/2024. Interviews with residents, staff, and witnesses stated that they have never been exposed to harmful chemicals. Staff have in house training where to store toxins and how to clean with toxins.

Based on records review, interviews with reporting party, staff, residents and witness the information provided, it was unclear if staff are exposing resident(s) to harmful chemicals therefore the allegation was deemed UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20231214111302
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: KIND CARE HOME II
FACILITY NUMBER: 502700517
VISIT DATE: 04/22/2024
NARRATIVE
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Staff did not assist resident with their cleaning needs – LPA Lund reviewed facility records, interviewed reporting party, staff, residents and witnesses. LPA Lund reviewed three residents (LIC625) Appraisal/Needs and Services Plans. Residents interviewed stated that their cleaning needs are being met by staff. Witnesses interviewed stated that their family members (Residents) cleaning needs are being met by staff.

Based on records review, interviews with reporting party, staff, residents and witness the information provided, it was unclear if staff did not assist resident with their cleaning needs therefore the allegation was deemed UNSUBSTANTIATED.

Facility refrigerator is in disrepair – LPA Lund interviewed reporting party, staff, residents, witnesses, and LPA Lund’s observation. LPA didn’t observe any of the two refrigerators and freezer to be in disrepair on during visits on 12/21/2023 and 4/22/2024. Interviews with residents, staff, and witnesses stated that they have never observed the refrigerators and freezer to be in disrepair.

Based on interviews with reporting party, staff, residents, witnesses and LPA Lund’s observation the information provided, it was unclear if facility refrigerator is in disrepair therefore the allegation was deemed UNSUBSTANTIATED.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is unsubstantiated.


An exit interview was conducted, and copies of the report and appeal rights left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20231214111302
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: KIND CARE HOME II
FACILITY NUMBER: 502700517
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2024
Section Cited
CCR
87303(a)
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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.
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Administrator Kash Kaur will do a in service regarding 87303(a) and email a copy of the inservice to LPA Lund by 4/23/2024.
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This requirement was not met as evidenced by: Based on 12/21/2023 LPA Lund observed all three bathrooms for residents in care not to be sanitary. This poses an immediate health and safety risk to residents 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: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4