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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005717
Report Date: 12/22/2022
Date Signed: 12/22/2022 09:41:46 AM

Substantiated


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
09/14/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220914154853
FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
347005717
ADMINISTRATOR:PARAMO, FERNANDOFACILITY TYPE:
740
ADDRESS:5725 KEVINBERG DRIVETELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Fernando ParamoTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Resident is being illegally evicted from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA explained the purpose of the visit and was met by administrator Fernando Paramo.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of LPA facility observations, interviews with staff, review of facility chart notes, interviews with residents, review of resident files and review of resident medical files.

The Department has determined the following as it relates to the allegation Resident is being illegally evicted from the facility

Continued on LIC 9099 - C...
Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
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 7
Control Number 27-AS-20220914154853
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: KEVINBERG CARE HOME
FACILITY NUMBER: 347005717
VISIT DATE: 12/22/2022
NARRATIVE
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Continues from LIC 9099

On 10/31/2022, LPA Ivey Canady interviewed facility administrator regarding R2 eviction. Administrator stated there was no knowledge that a request for eviction had to be submitted to Community Care Licensing for approval and R2 had been evicted on 9/20/2022 by way of being dropped off at the hospital emergency room. On 12/20/2022, LPA interviewed administrator and learned that a doctor at the hospital sent R2 to a nursing care facility. According to interview with administrator, and records received from administrator, R2 was given an eviction notice on 12/23/2021 and 05/28/2022. Based on document and file research at Community Care Licensing (CCL), the Department did not receive or approve a request to evict R2 from Licensee. According to facility notes received on 11/03/2022 R2 received an eviction notice due to loud playing electronics. LPA Ivey Canady attempted to reach R2 for an interview and was not successful. However, in accordance with Title 22 regulations, the allegation Resident is being illegally evicted from the facility is Substantiated.

Based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220914154853
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: KEVINBERG CARE HOME
FACILITY NUMBER: 347005717
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2023
Section Cited
CCR
87224(f)
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87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by:
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Licensee stated the review of Title 87224 will be conducted with management/licensee staff. An in-service sign in sheet and statement acknowledging policies and procedures will be sent to LPA Ivey Canady by POC due date.
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Based on interviews and records review, the licensee did not ensure CCL was notified for R1's eviction. This poses a potential 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
09/14/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220914154853

FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
347005717
ADMINISTRATOR:PARAMO, FERNANDOFACILITY TYPE:
740
ADDRESS:5725 KEVINBERG DRIVETELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Fernando ParamoTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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9
Licensee is emotionally abusive to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA explained the purpose of the visit and was met by administrator Fernando Paramo.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of LPA facility observations, interviews with staff, review of facility chart notes, interviews with residents, review of resident files and review of resident medical files.

The Department has determined the following as it relates to the allegation Licensee is emotionally abusive to resident

Continued on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
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 7
Control Number 27-AS-20220914154853
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: KEVINBERG CARE HOME
FACILITY NUMBER: 347005717
VISIT DATE: 12/22/2022
NARRATIVE
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...Continued from LIC 9099 - A

On 10/31/2022, LPA Ivey Canady interviewed facility residents regarding current allegation. All residents report a peaceful and happy environment within the facility. During the interviews, residents were questioned if there was any direct or indirect knowledge of emotional abuse occurring in the facility from Licensee to resident. Residents report no knowledge of direct or indirect emotional abuse. LPA Ivey Canady interviewed staff at the facility regarding current emotional abuse allegations. 2 out of 2 Staff have not witnessed abuse from Licensee to resident. However, 1 out of 2 Staff did report instances that could indirectly be perceived as emotional abuse; however, staff stated the information came from hear say. LPA Ivey Canady requested and received facility chart notes, staff notes, resident files, and resident medical files. According to review of files and documents received, there are no written occurrences regarding direct or indirect emotional abuse from Licensee to resident, therefore the allegation Licensee is emotionally abusive to resident is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
09/14/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220914154853

FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
347005717
ADMINISTRATOR:PARAMO, FERNANDOFACILITY TYPE:
740
ADDRESS:5725 KEVINBERG DRIVETELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Fernando ParamoTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Licensee is physically abusive to other residents
Facility did not give resident a 60-day written notice of increase in rent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA explained the purpose of the visit and was met by administrator Fernando Paramo.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of LPA facility observations, interviews with staff, review of facility chart notes, interviews with 3 out of 4 residents, review of resident files and review of resident medical files.

The Department has determined the following as it relates to the allegations Licensee is physically abusive to other residents and Facility did not give resident a 60-day written notice of increase in rent.

Continued on LIC 9099 - C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20220914154853
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: KEVINBERG CARE HOME
FACILITY NUMBER: 347005717
VISIT DATE: 12/22/2022
NARRATIVE
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Continued from LIC 9099 - A

On 10/31/2022, LPA Ivey Canady interviewed residents regarding current allegations. According to interviews with R3 and Licensee on R3 stated on 10/13/2022 at 9:30 am, R3 attempted to help R1 transport to a chair. R1 fell against the chair while attempting to sit. According to interviews with R3 and Licensee, Licensee heard the fall and attempted to assist. Licensee recognized R1 sustained bruising from the fall and notified the agency R1 was receiving hospice services from. According to medical record review, Licensee reported fall incident on 10/13/2022 to hospice care services. Based on interviews with residents and staff and medical file and chart review, the allegation Licensee is physically abusive to other residents is Unfounded. Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

On 10/31/2022 and 12/20/2022, LPA Ivey Canady requested, received, and reviewed facility Plan of Operation and Admission Agreement for R2. According to admission agreement for R2, verbiage reads “If a resident’s level of care or service needs changes, the rate may be increased immediately. Admission agreement is signed by R2 and dated 2/21/2021. In accordance with facility Plan of Operation, Licensee initialized an increased fee based on an increased need for level of care and was within the rights stated by the facility Plan of Operation and R2 admission agreement to increase rates of care for service. Therefore, the allegation Facility did not give resident a 60-day written notice of increase in rent is unfounded. Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7