<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700317
Report Date: 05/13/2025
Date Signed: 05/13/2025 09:34:33 AM

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
01/22/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250122110921
FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR:NELSON JACINTOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:24CENSUS: 22DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Nelson JacintoTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not seek timely medical attention for resident.
Resident sustained multiple falls while living at the facility due to Neglect/Lack of Care and Supervision by staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/13/25 to deliver the complaint findings for above allegations. LPA met with administrator Nelson Jacinto and explained the purpose of the visit.


The department conducted records review ,staff and residents interviews to investigate the complaint.



**Report continued on LIC9099-C**
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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 5
Control Number 59-AS-20250122110921
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: GRACE HOME II
FACILITY NUMBER: 342700317
VISIT DATE: 05/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***Report continued from 9099....
Allegation- Neglect/Lack of Care and Supervision: facility staff failed to seek timely medical attention for resident, R1- Substantiated

Department conducted record review and staff’s interviews to investigate this allegation. Record review reflected that resident, R1 showed a decline, fall of 2024 in their overall physical and cognitive abilities. R1 had several falls, failed to sleep at night, and needed a higher level of care. On 01/14/2025, R1 had a fall at day program, R1 was evaluated by day program staff and determined to not have any injuries. The following day, 01/15/2025, R1 had a change of condition and was too weak to stand up out of bed. There was inconsistent information as staff stated during investigation that staff assisted R1 into a wheelchair where they spent the day however EMT records indicated staff stated that R1 was not seen out of their room in 48 hours. On 01/16/2025, R1 still could not stand up or transfer without assistance, that was when staff called 911 and decided to transport him to the hospital. It was noted by facility staff and day program staff that R1 would constantly walk, and it was hard for staff to get them to sit still.

Per R1s Medical records review, upon R1’s arrival to the hospital, R1’s temperature was 30.8 °C, blood pressure 93/61, bradycardic at 55, EKG showed sinus bradycardia, chest x-ray showed bibasilar consolidation left greater than right. CT chest abdomen pelvis shows bilateral pneumonia, aspiration possibility, air-filled esophagus, moderate to severe pancreatitis. Posterior aspect of the left temporal lobe shows moderate encephalomalacia. Moderate cortical sulcal widening.

R1 passed away at hospital on 01/28/2025 due to Cardiopulmonary arrest, acute respiratory failure and multifocal pneumonia and acute respiratory distress syndrome.

Staff interviews indicated that, based on R1’s care needs they needed a higher level of care. Licensee, Nelson Jacinto was aware R1 was a fall risk, however the facility failed to put a plan into place. Interviews indicated R1 should not have been in the facility due to their care needs and preemptively wrote a (60-Day Notice to Vacate) for R1 on 10/02/2024, however R1 was never served the eviction notice. Based on interviews and records review, R1 had an obvious change of condition after a fall but facility staff failed to seek medical attention in timely manner, therefore, the allegation is Substantiated.

....report continued.....
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250122110921
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: GRACE HOME II
FACILITY NUMBER: 342700317
VISIT DATE: 05/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
.....report continued.......

Allegation- Neglect/Lack of Care and Supervision: Resident, R1, sustained multiple falls while living at the facility due to Neglect/Lack of Care and Supervision by staff. -Substantiated

Department conducted record review and staff’s interviews to investigate this allegation. It was noted during record review that, between 2/03/2024 to 1/14/2025, resident, R1, sustained 13 falls with a majority of the falls being from 8/2024 to 1/14/2025 (10 falls). Interviews and documents reviewed indicated the facility had no plan of action to assist in mitigating R1’s falls. R1’s care plan was not updated, and R1 was not made a fall risk. Facility staff stated they tried to have R1 use a walker or wheelchair, but R1 refused. Staff interviews stated, “they cannot force residents to do something they don’t want to.” R1 attended a Day program. Interviews with Day Program staff stated R1 was noted as a fall risk and implemented a plan resulting in R1 only utilizing a wheelchair while at the day program. Day program had no issues having R1 in a wheelchair. Grace Home II failed to implement the same fall mitigation plan for R1.
Licensee/Owner, Nelson Jacinto admitted during his interview he knows there should have been a fall plan put in place and the facility failed to act. Nelson Jacinto and staff attempted to blame R1’s responsible party (RP) as RP did not give them a plan of action.

Based on investigation conducted, facility staff were aware R1 was a fall risk and did not put measures in place to provide adequate care and supervision to R1 resulted in R1 sustaining multiple falls and did not seek timely medical care to address R1s health condition that contributed to R1’s death. Based on the facility failing to implement any sort of plan of action to mitigate R1s falling and staff failing to remove R1 from the facility after there were clear signs facility was aware they could no longer meet R1’s needs, the allegation is Substantiated. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegations are found to be SUBSTANTIATED.

The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident, R1s death due to facility’s lack of care and supervision. Failure to correct the deficiencies may also result in civil penalties. Please see LIC9099-D for deficiencies cited today.

Exit interview conducted. Appeal Rights provided. A copy of the report issued.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20250122110921
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: GRACE HOME II
FACILITY NUMBER: 342700317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2025
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466-Observation of the Resident- licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs……. This requirement is not as evidence by….
1
2
3
4
5
6
7
Licensee will make sure that Observation of for any resident per their health care needs/changes will be done in timely manner so residents care needs can be met per RCFE regulation 87466. Licensee shall submit letter of understanding of this regulation to CCL by POC date-05/14/25. resident’s who are identified as a fall risk.
8
9
10
11
12
13
14
Based on record review and interviews, it has been concluded that facility did not reassess R1 for unmet needs despite multiple falls incidents from 08/2024 till 01/15/25, which poses immediate health and safety risks for residents in care.
8
9
10
11
12
13
14
Additionally, the facility shall develop a plan on how the facility will address resident’s who are identified as a fall risk.

Immediate civil penalty of $500.00 was assessed during today’s visit.


Type A
05/14/2025
Section Cited
CCR
87463(a)
1
2
3
4
5
6
7
87463(a) Reappraisals- The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months......... This requirement is not as evidence by…
1
2
3
4
5
6
7
Licensee will make sure that Reappraisals requirements all residents can be met per RCFE regulation 87463. Licensee shall submit letter of understanding of this regulation to CCL by POC date-05/14/25.
8
9
10
11
12
13
14
Based on record review and interviews, it has been concluded that facility did not provide proper care and supervision for R1 which resulted R1s fall and death on 01/28/25 which poses an immediate health and safety risks for residents in care.
8
9
10
11
12
13
14
Additionally, the facility shall submit an addendum to the facility plan of operation regarding reappraisals addressing regulation requirements.
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: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
01/22/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250122110921

FACILITY NAME:GRACE HOME IIFACILITY NUMBER:
342700317
ADMINISTRATOR:NELSON JACINTOFACILITY TYPE:
740
ADDRESS:9260 LOMA LANETELEPHONE:
(916) 607-6225
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:24CENSUS: 22DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Nelson JacintoTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to notify family of change of condition of resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/13/25 to deliver the complaint findings for above allegation. LPA met with administrator Nelson Jacinto and explained the purpose of the visit.

Based on R1’s facility admission agreement and admission paperwork, R1 is their own responsible party. Based on the documentation reviewed, the allegation' Facility failed to notify family of change of condition of resident' is UNFOUNDED.
Based on the investigation,the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

Exit meeting conducted and a copy of this report has been provided to facility.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5