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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002925
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:23:58 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/03/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230103131124
FACILITY NAME:LOVING-KINDNESS CAREHOME LLCFACILITY NUMBER:
315002925
ADMINISTRATOR:NINOBLA, DERBBIEFACILITY TYPE:
740
ADDRESS:912 OAK RIDGE DRTELEPHONE:
(916) 297-7694
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 3DATE:
03/29/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator: Derbbie Ninobla TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Facility staff did to address issue with scabies.
INVESTIGATION FINDINGS:
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On 03/29/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced and met with Administrator, Derbbie Ninobla, to deliver final finding for a complaint Community Care Licensing (CCL) received on 01/03/2023. LPA wore Surgical Mask and was screened by facility upon entry.

During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, needs and services plan, appraisals, and medical records.

According to complainant, the facility has currently been found to be infested with scabies. R1 was found to have scabies across the chest area since R1 moved into the facility.

Continue on page LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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 25-AS-20230103131124
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: LOVING-KINDNESS CAREHOME LLC
FACILITY NUMBER: 315002925
VISIT DATE: 03/29/2023
NARRATIVE
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The Department received an interview statement from the facility’s administrator. On 12/22/2022, administrator stated R1 was sent to the hospital due to a change of condition. Administrator received a text message from R1 stating, R1 will be receiving surgery for scabies and other physical issues. The same day R1 notified administrator of scabies, administrator contacted Doctor/Nurse and confirmed there were no scabies involved and R1 was experiencing itchiness in the chest area.

The Department received R1’s medical records for review. According to medical records, R1 was admitted to the hospital on 01/07/2023. Medical records does not indicate R1 was diagnosed with scabies.

Based on information above, the Department concluded that all these allegations are UNFOUNDED. A finding that the allegation are unfounded means that the allegation are false, could not have happened, and/or is without a reasonable basis.

No citations were issued today.

Exit interview was conducted with administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
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