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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700570
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:49:03 PM

Substantiated


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
03/30/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230330121217
FACILITY NAME:SEN'S CAREGIVINGFACILITY NUMBER:
342700570
ADMINISTRATOR:PRASAD, INDRA SENFACILITY TYPE:
740
ADDRESS:5250 SHORTWAY DRTELEPHONE:
(916) 471-9145
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 3DATE:
04/07/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Indra Prasad, Licensee/AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident wandered away from facility due to lack of supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility on 4/7/2023 to commence a complaint investigation with the allegation above. LPA met with Administrator Indra Prasad and explained the purpose of today’s visit.

During today’s visit, LPA conducted interviews and reviewed records. Based on the interviews conducted and reviewed of records, it was learned that on 2/17/23 resident (R1) AWOL’D out of the side gate of the facility without staff knowledge. Based on staff statement, R1 was sitting in the backyard and has left the facility by walking through the side gate. It was determined that R1 was sitting in the backyard and left the facility without staff supervision.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
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 5
Control Number 27-AS-20230330121217
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: SEN'S CAREGIVING
FACILITY NUMBER: 342700570
VISIT DATE: 04/07/2023
NARRATIVE
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Based on interviews conducted, and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations.

Exit interview conducted, a copy of this report, LIC 9099-D, and appeal rights were provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230330121217
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: SEN'S CAREGIVING
FACILITY NUMBER: 342700570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met by:
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The Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall submit the in-service training materials and plan of correction on how facility will ensure residents do not AWOL and sent a signature sheet of all staff who attended to LPA by POC date.
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Based on interviews and record review, the Licensee did not ensure adequate supervision of residents in care. Resident R1 AWOL'd from the facility on 2/17/2023. This poses an immediate health and safety risk to the resident in care.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/30/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230330121217

FACILITY NAME:SEN'S CAREGIVINGFACILITY NUMBER:
342700570
ADMINISTRATOR:PRASAD, INDRA SENFACILITY TYPE:
740
ADDRESS:5250 SHORTWAY DRTELEPHONE:
(916) 471-9145
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 3DATE:
04/07/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Indra Prasad, Licensee/AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained an unexplained black eye while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility on 4/7/2023 to commence a complaint investigation with the allegation above. LPA met with Administrator Indra Prasad and explained the purpose of today’s visit.

During today’s visit, LPA conducted interviews and reviewed records. Based on the interviews and statements obtained during the investigation, it was determined that there was insufficient evidence to substantiate that resident (R2) has sustained an unexplained black eye while in care. R2 was unable to articulate when LPA asked if R2 has had a black eye. LPA asked R2 if she was abuse or if someone has hit her, R2 shook her head indicating ‘no’. Resident interviewed stated that they have no concerns with care.

Report continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230330121217
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: SEN'S CAREGIVING
FACILITY NUMBER: 342700570
VISIT DATE: 04/07/2023
NARRATIVE
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Based on information obtained, LPA finds the allegation above 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 and a copy of the report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5