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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 095002919
Report Date: 11/08/2023
Date Signed: 11/08/2023 10:09:42 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
10/17/2023 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20231017164751
FACILITY NAME:PLEASANT CARE HOMEFACILITY NUMBER:
095002919
ADMINISTRATOR:SEPULVEDA, LINAFACILITY TYPE:
740
ADDRESS:4880 RIVENDALE RD.TELEPHONE:
(530) 647-2899
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:6CENSUS: 3DATE:
11/08/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Lina SepulvedaTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Staff yelled at resident.
INVESTIGATION FINDINGS:
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On 11/8/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lina Sepulveda.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
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 59-AS-20231017164751
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PLEASANT CARE HOME
FACILITY NUMBER: 095002919
VISIT DATE: 11/08/2023
NARRATIVE
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Staff yelled at resident.
The department conducted interviews with staff and residents and reviewed records to investigate the allegation. Interviews indicated that S1 admitted that on 10/14/23, S1 did speak a little loudly when S1 found R1 sliding down on R1s recliner. S1 thought R1 was injured and S1 panicked and said, “this is so dangerous, please don’t do this without asking for help”. Staff spoke a bit louder as R1 has trouble hearing. R1 has a habit of moving from bed to recliner during the night. R1 was not injured in the process. At the time of incident, on 10/14/23, it is not possible to say with certainty what a staff or resident may perceive as yelling, or what a particular tone of voice may sound like to someone else. Therefore, the department is not able to conclude if S1 was in fact intending to yell or did yell at a resident; or if S1’s voice was perceived as yelling. Therefore, the allegation is 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.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2