502700543-7-28-2022-27-AS-KHOS-CHDPAU-20220817110919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700543
Report Date: 07/28/2022
Date Signed: 07/28/2022 05:42:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2022 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220425120149

FACILITY NAME:	AG ADULT RESIDENTIAL CARE HOME		FACILITY NUMBER:	502700543
ADMINISTRATOR:	NKWOCHA, ONYEMA		FACILITY TYPE:	735
ADDRESS:	3829 WILD PALMS DR		TELEPHONE:	(209) 275-3272
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	4	CENSUS: 4	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Onyema Nkwocha		TIME COMPLETED:	01:33 PM

ALLEGATION(S):

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Residents are being served unsafe food.
Residents are being verbally abused while in care.
Resident was hit while in care.
Resident was confined while in care.

INVESTIGATION FINDINGS:

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Allegation:Residents are being served unsafe food.

Based on inspection of the food and review of the menu along with resident interviews the facility has a variety of available foods for all meals along with snacks that are available for the residents to have as they please. During the inspection of the food LPA observed no foods with expiration dates and the fruits was fresh.

Allegation: Residents are being verbally abused while in care.

Residents interviewed denied being spoke to unprofessionally or without repect. The staff interviewed denied speaking to the residents with disrepect or verbally abusing them, the Administrator confirmed that the staff treat the residents with respect and he has not heard staff be verbally abusive toward the residents.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220425120149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AG ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 502700543
	VISIT DATE: 07/28/2022

NARRATIVE

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Allegation: Resident was hit while in care.

Residents interviewed denied being hit by staff, spoke to unprofessionally or without respect. The staff interviewed denied hitting, speaking to the residents with disrespect or verbally abusing them, the Administrator confirmed that the staff treat the residents with respect and he has not heard staff be verbally abusive toward the residents or witnessed staff hitting residents or hitting the residents himself.

Allegation: Resident was confined while in care.

Residents interviewed denied being confined to their rooms and are able to move about the facility freely. The residents mentioned that they are not allowed to go into the staff's office, but have the ability to go every where else. The Administrator confirmed that he has not witnessed residents being confined to their rooms. The facility has an activity schedule and if the residents decide not to participate they can do any other activity they would like to engage in including watching T.V. or going in the backyard or anything within reason.

As a result of this investigation, LPA finds the allegations to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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