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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700416
Report Date: 07/13/2023
Date Signed: 07/13/2023 03:58:34 PM

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
03/28/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230328154729
FACILITY NAME:ELDERLY INN IV, THEFACILITY NUMBER:
342700416
ADMINISTRATOR:TOPLEAN, SAMFACILITY TYPE:
740
ADDRESS:4908 ILLINOIS AVETELEPHONE:
(916) 844-7025
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
07/13/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Marinela "Mary" Barac, Acting AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents are chemically restrained with medication

Facility staff are not fingerprint-cleared

Staff are using drugs while on duty

Facility staff are abusing residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Michael Hood and Angela Hood arrived at the facility and met with Acting Administrator, Marinela "Mary" Barac, to deliver findings into the allegations listed above. LPAs spoke with Licensee, Sam Toplean, via phone call. Licensee gave permission to have Acting Administrator sign report.

During the course of the investigation, interviews were conducted, a medication count was conducted for residents (R1, R2, & R3), and documentation pertinent to the investigation was obtained. LPAs did not find any errors for Hydrocodone for R1. LPAs reviewed facility roster indicating that all staff working at the facility are criminal background check cleared. Interviews conducted with staff (S1 & S2) as well as R1 and resident (R4) indicated that they have never witnessed staff using drugs while on duty. Interviews with R1 and R4 indicated that they have never experienced abuse or witnessed staff abusing residents in care. Interviews with S1 and S2 indicated that they have not witnessed staff abusing residents.

Based on interviews conducted, documentation reviewed, and medication count, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited during this visit.

Exit interview conducted. A copy of the report was provided to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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