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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 576804111
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:02:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240710122708
FACILITY NAME:ELDERLY CARE ON CALMIAFACILITY NUMBER:
576804111
ADMINISTRATOR:ROBERT COLEMANFACILITY TYPE:
740
ADDRESS:4220 CALMIA PLACETELEPHONE:
(410) 961-3870
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:6CENSUS: 5DATE:
07/24/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Paulin Pantig, House ManagerTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff are not providing a comfortable temperature for the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at approximately 2:15 PM on 7/24/2024 to deliver findings of the complaint investigation regarding the above allegations and met with House Manager, Paulin Pantig. LPA conducted interviews and made observations.

During the visit on 7/10/2024, LPA made the following observations:
• Facility's thermostat was inoperable due to power outages throughout the facility. External temperature had been over 105 the last several days; LPA’s thermometer read 91.4 degrees F. at the time of inspection in the dining room of the facility.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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
Control Number 21-AS-20240710122708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELDERLY CARE ON CALMIA
FACILITY NUMBER: 576804111
VISIT DATE: 07/24/2024
NARRATIVE
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Continued from 9099......
Multiple fans were running in the facility and multiple room air conditioning units were providing cooling to residents’ bedrooms, using extension cords running from neighbors’ homes. Main circuit breaker to the facility was not working properly and main air conditioning unit was inoperable at the time of inspection.

Per Licensee, the air conditioning unit had been installed 2 weeks ago and there had been no problems until the extreme heat wave had presented issues to the power grid and the facility had been experiencing intermittent power outages.

During the inspection, the Administrator delivered additional portable air conditioning units to the facility, installed window coverings to help keep heat out of facility, contacted PG &E and electrical/air conditioning repair company to correct problems. Due to unreliable and inadequate power source and the facility's inability to power the portable air conditioning units the facility's emergency plan was initiated and residents and staff were evacuated to a nearby hotel until repairs could be made and facility’s temperature could be regulated to within regulation.

Based on LPA’s interviews conducted and observations made, the preponderance of evidence standard has been met, therefore the allegation that Staff are not providing a comfortable temperature for residents is substantiated. Based on California Code of Regulations, (Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.”) A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Appeal Rights, and Plan of Corrections Letter discussed and provided to Paulin Pantig, House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20240710122708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ELDERLY CARE ON CALMIA
FACILITY NUMBER: 576804111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/24/2024
Section Cited
CCR
87303(b)(2)
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87303 Maintenance and Operation:(b) A comfortable temperature for residents shall be maintained at all times. (2)The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C)and 85 degrees F(30 degrees C)..
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Licensee to put in writing their plan in the event of a future power outage and provide proof of training to staff of said plan to CCL by 7/26/2024.
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This requirement was not met as evidenced by: interviews conducted, and observations made, Licensee did not ensure that temperatures in the facility were within regulation. Facility temperatures were observed by LPA to be 91.4 degrees on 07/10/2024.
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240710122708

FACILITY NAME:ELDERLY CARE ON CALMIAFACILITY NUMBER:
576804111
ADMINISTRATOR:ROBERT COLEMANFACILITY TYPE:
740
ADDRESS:4220 CALMIA PLACETELEPHONE:
(410) 961-3870
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:6CENSUS: 5DATE:
07/24/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Paulin Pantig, House ManagerTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility is in disrepair
Staff are mishandling the residents’ medications

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 7/10/2024 to investigate the allegations that the Facility is in disrepair and Staff are mishandling the residents’ medications. LPA conducted an inspection of the facility and found medications were being stored correctly at the time of inspection; locked and inaccessible to residents in care. LPA also found that, although the facility was experiencing some electrical problems the Licensee was addressing the problems (which had been brought on by the extended unseasonable heat – not because of neglect of facility upkeep/maintenance) and had arranged repairs to be made as quickly as possible. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are
unsubstantiated.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4