342700456-7-9-2021-27-AS-CACL-C4VSAD-20210713134211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700456
Report Date: 07/09/2021
Date Signed: 07/09/2021 10:09:58 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/29/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210329120627

FACILITY NAME:	A FAMILY AFFAIR CARE II		FACILITY NUMBER:	342700456
ADMINISTRATOR:	MITCHELL, KASSIA		FACILITY TYPE:	740
ADDRESS:	7526 21ST STREET		TELEPHONE:	(916) 919-4590
CITY:	SACRAMNETO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 6	DATE:	07/09/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Kassia Mitchell, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Suspected physical abuse of resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver investigation findings on 7/9/2021. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with administrator Kassia Mitchell.

The investigation was conducted by the Department which consisted of reviews of the facility records and interviews with facility management and staff. The resident (R1) and other witnesses were contacted and interviewed. The complaint alleges that resident R1 sustained a fibula tibia fracture to the right lower leg as a result of abuse.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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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Control Number 27-AS-20210329120627

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A FAMILY AFFAIR CARE II	FACILITY NUMBER: 342700456
	VISIT DATE: 07/09/2021

NARRATIVE

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During the investigation, it was revealed that R1 had two falls while at a Skilled Nursing Facility (SNF). After discharged from SNF on 2/17/2021, R1 had ongoing issues with a sore to the right toe and swelling of lower right leg. Resident R1 was diagnosed with a tibia fracture on 3/10/2021. When interview R1, R1 was not able to speak to the cause of injury. Administrator Kassia Mitchell reported that R1 is non-verbal at baseline. Administrator Kassia Mitchell stated she was not aware of how R1’s leg was injured. Administrator Kassia stated she had no idea as to what could have caused the fracture and denied any time that R1 fell while in her care. Staff (S1) denied anything occurred that would have caused R1's leg to got injured. Staff (S2) did not know how R1’s injury occurred. Other residents in care that were interviewed did not know how R1’s leg got injured.

The investigation revealed the lack of evidence to substantiate that resident R1 was being physically abused while in care. Investigation revealed the cause of R1’s leg injury was unknown.

This Department has investigated the complaint alleging the above allegation to be 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 Kassia Mitchell and a copy of the report was provided.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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