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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700543
Report Date: 08/04/2022
Date Signed: 08/05/2022 08:59:29 AM

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
04/27/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220427091058
FACILITY NAME:AG ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
502700543
ADMINISTRATOR:NKWOCHA, ONYEMAFACILITY TYPE:
735
ADDRESS:3829 WILD PALMS DRTELEPHONE:
(209) 275-3272
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:4CENSUS: 4DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sheriff KabbaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident was left unsupervised while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced facility visit on 08/04/2022 to deliver complaint findings. LPA Pascua was greeted by caregiver, Sheriff Kabba and was told to contact the Administrator to let them know that CCL was present at this time. Shortly after, LPA Pascua met with Facility Designated Administrator, Oynema Nkwocha and explained the purpose of the visit.
Current census is 4.
Throughout the course of this investigation, LPA Pascua conducted interviews and reviewed facility documents.
Allegation: Resident was left unsupervised while in care.
Based on resident records and interviews conducted, it was learned that this facility had 3 staff members during the day shift and 2 staff members during the night shift. The facility also had records to record PATCH hours for R1 during their time at the facility. Based on interviews and resident records, it is unclear that the resident was unsupervised at any moment while in the facilities care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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
Control Number 27-AS-20220427091058
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: 08/04/2022
NARRATIVE
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As a result of this investigation, the Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited per Title 22 Regulations. Exit interview was conducted and a copy of this report was given to the Facility Designated Administrator, Oynema Nkwocha.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/27/2022 and conducted by Evaluator Arielle Pascua
COMPLAINT CONTROL NUMBER: 27-AS-20220427091058

FACILITY NAME:AG ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
502700543
ADMINISTRATOR:NKWOCHA, ONYEMAFACILITY TYPE:
735
ADDRESS:3829 WILD PALMS DRTELEPHONE:
(209) 275-3272
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:4CENSUS: 4DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sheriff KabbaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident's personal belongings were not safeguarded.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced facility visit on 08/04/2022 to deliver complaint findings. LPA Pascua was greeted by caregiver, Sheriff Kabba and was told to contact the Administrator to let them know that CCL was present at this time. Shortly after, LPA Pascua met with Facility Designated Administrator, Oynema Nkwocha and explained the purpose of the visit.
Current census is 4.
Throughout the course of this investigation, LPA Pascua conducted interviews and reviewed facility documents.
Based on resident records and interviews conducted, it was learned that the facility did not have an initial inventory list for R1 during the move in on 07/17/2021. An inventory list was created on 08/11/2021 and was edited on 09/01/2021. A separate inventory list was created for the items removed from R1’s room was dated on 03/10/2022 LPA Pascua compared the two inventory lists from 08/11/2021 and 03/10/2022 and both documents do not show the same items. As a result, the Administrator did not follow the facility's Plan of Operation policies.
As a result of this investigation, this LPA finds the allegation to be SUBSTANTIATED-A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code.
Exit interview was conducted, a copy of this report and appeal rights were left with Facility Designated Administrator, Oynema Nkwocha.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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-20220427091058
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited
CCR
80026(h)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care
This requirement is not met as evidenced by:
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Licensee agrees to create inventory lists for all incoming move-ins in the future, and create an updated inventory list for all current residents by 08/19/2022
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Based on interviews and review of facility records, the Licensee did not maintain accurate records of R1s personal property inventory during placement which contributed to the failure to protect R1’s personal property.
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4