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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002812
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:19:30 PM

Substantiated


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
10/22/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20241022104408
FACILITY NAME:BLESSED HOMECARE 2 ROSEVILLEFACILITY NUMBER:
315002812
ADMINISTRATOR:ARGANA, FERDINANDFACILITY TYPE:
740
ADDRESS:4100 SHORTHORN WAYTELEPHONE:
(209) 834-4040
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Leriza "Riza" ArambuloTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Resident able to leave the facility unnoticed by staff.
Facility did not contact 9-1-1 timely regarding resident leaving the facility unnoticed
Facility is obstructing fire exits.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson, conducted this unannounced complaint visit.

LPAs interviewed Caregivers and Licensee Baby Quintero via the phone. LPAs toured the facility and reviewed resident files.

On 10/21/2024, a resident was able to leave the facility without staff noticing. The resident is a known wander risk. The facility staff were assisting other residents when the one left out the side gate. The facility has audio alerts on the doors as required by Title 22 Regulations if exiting poses a risk to residents and in this case exiting does pose a risk to residents but the audio alerts were turned off due to the batteries not working. The facility also does not have a staffing plan to address the issue of two residents who make attempts to leave the facility. The two residents were determined by their doctors to not be able to leave the facility unassisted. This is a $500.00 immediatel civil penalty because the resident was able to leave the facility unnoticed by staff.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 59-AS-20241022104408
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: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812
VISIT DATE: 10/24/2024
NARRATIVE
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Licensee Baby Quintero, stated she did not wait one hour to call 911 to report the resident missing. Licensee stated it was probably 30 minutes because she and her staff went around the neighborhood looking for the resident first. Title 22 Regulations does not have time limits to call for emergency services; however, this resident has a diagnosis of dementia and per the physician, this resident was unable to leave the facility unattended and was found about four blocks away unharmed. Because the Licensee waited before calling emergency services the allegation is substantiated.

When LPAs arrived at the facility and was waiting for someone to answer the front door, LPAs observed a sound like something was being moved from in front of the front door. Upon entering the front door LPAs observed two chairs placed directly to the left of the front door which put them behind the open door. LPAs asked the caregiver who answered the front door what the chairs were for and the caregiver admitted to blocking the front door with the chairs to prevent the residents from leaving through the front door. Licensee Baby Quintero, also stated she had the chairs placed in front of the door along with a can so the staff can hear the chairs and can being moved so they can get to the residents before the residents are able to open the front door. LPAs also observed a wood rod placed in the sliding glass door to prevent it from opening. This is a fiire safety violation. This is a $500.00 immediate civil penalty for blocking exits.

As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. A total of $1000.00 Immediate Civil Penalties Assessed during today's visit.
Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Failure to correct the deficiencies may result in Civil penalties being assessed.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20241022104408
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: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
HSC
1569.312(e)
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Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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By 10/25/2024, the licensee shall come up with a written plan of correction that specifies how the residents shall be monitored, how staff are going to be trained to monitor the residents, and how she is going to ensure the staff are monitoring the residents. Licensee shall submit this plan to Community Care
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Licensee failed this by a resident leaving the facility through the side gate unnoticed by staff. This is an immedate health and safety risk to residents
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Division. $500.00 Immediate civil penalty assessed.
Type A
10/25/2024
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...
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By 10/25/2024, Licensee shall come up with a plan addressing residents who leave the facility without assistance and unoticed. This plan shall address what steps shall be taken to find the missing resident. Licensee shall submit this plan to Community Care Licensing Division.
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Licensee failed this because a resident left the facility unassisted and the Licensee did not call for emergency services for at least 30 minutes. This poses an immediate risk to residents.
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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: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20241022104408
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: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
87203
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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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By 10/25/2024, Licensee shall come up with a written plan for staf to address monitoring of residents who are wander risks. This plans shall also address staffing needs because if the staff on duty are assisting other residents and that leaves no staff to monitor the rest of the residents the licensee shall have another
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Licensee failed to meet this because the front door was blocked by two chairs and the sliding glass door had a wood rod placed at the bottom in the track to prevent the door from being opened. This is an immediate risk to residents.
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staff on duty. Licensee shall include staff training and how often she is going to train staff.
$500.00 immediate civil penalty
Type A
10/25/2024
Section Cited
CCR
87307(d)(6)
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Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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By 10/25/2024, the licensee shall ensure no walkways, doorways, etc., are blocked by anything. The licensee shall submit a written statement stating she understands she cannot do this and how she shall ensure no walkways, doors, etc., are blocked.
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Licensee failed to meet this because the front door was blocked by two chairs and the sliding glass door had a wood rod placed at the bottom in the track to prevent the door from being opened. This is an immediate risk to residents.
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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: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4