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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700526
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:06:33 PM

Unsubstantiated


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
05/08/2024 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20240508124544
FACILITY NAME:MIH-3 CARE HOMEFACILITY NUMBER:
502700526
ADMINISTRATOR:RYAN, MICHAELFACILITY TYPE:
735
ADDRESS:5413 FARMERS LNTELEPHONE:
(209) 244-3898
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:4CENSUS: 4DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Manager Monica AbricaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not dispense medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation. LPA Lund met with Manager Monica Abrica and explained the reason for the visit. Census:4

Staff did not dispense medication as prescribed- Based on records reviewed, interviews with client, reporting party, and staff. On 4/19/2024 Clinet (C1) was out of the facility with C1’s mother. C1 and C1’s mother stated to the facility that they would be back before C1’s 8:00 PM med pass. C1 didn’t return to the facility until 9:42 PM and missed the one- hour window of giving the medications to C1. C1’s asked Staff (S1) for C1’s medication and when S1 was checking with management about the situation C1’s mother left and took C1 to the Emergency room and got C1 his medication. LPA Lund requested a copy of such records and didn’t receive a copy from C1’s mother. S1 signed a 7 Right of Medication Administration on 9/1/2023 that states on #5 (Right time) that medication is give one hour before prescribed time or one hour after prescribed time.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
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 2
Control Number 27-AS-20240508124544
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: MIH-3 CARE HOME
FACILITY NUMBER: 502700526
VISIT DATE: 08/02/2024
NARRATIVE
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Based on records review, interviews with client, reporting party, and staff the information provided, it was unclear if staff did not dispense medication as prescribed based on behavior therefore the allegation was deemed UNSUBSTANTIATED.

The Department (CCLD) has found the allegations. Unsubstantiated.
A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Exit interview was conducted with and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2