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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700585
Report Date: 06/04/2021
Date Signed: 06/04/2021 02:54:20 PM

Unfounded


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
05/17/2021 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210517085346
FACILITY NAME:INDOCARE HOUSE 2FACILITY NUMBER:
342700585
ADMINISTRATOR:LOMENDEHE, PAULFACILITY TYPE:
740
ADDRESS:8604 BANFF VISTA DRTELEPHONE:
(916) 686-1253
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
06/04/2021
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Orpha Manalansan, Lead CaregiverTIME COMPLETED:
02:53 PM
ALLEGATION(S):
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Staff hitting resident resulting in bruising
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced complaint visit at the facility and met with lead caregiver Orpha Manalansan to discuss and complete this complaint investigation. Administrator Paul Lomendehe was informed of the purpose of this visit by LPA and gave permission via phone to allow lead caregiver to accept findings and provide signatures. LPA provided findings regarding the allegation listed above. The investigation was conducted by the Investigation Branch (IB) and consisted of reviews of the facility records and interviews with facility management and staff as well as hospital staff and resident’s responsible party. The resident was also contacted and interviewed by IB.

The complaint alleges that staff hit resident and caused bruising to resident while in care. The resident facility staff and management and other witnesses were interviewed by the Investigator. The resident denied that the allegation occurred.

(Cont. on 9099C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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 27-AS-20210517085346
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: INDOCARE HOUSE 2
FACILITY NUMBER: 342700585
VISIT DATE: 06/04/2021
NARRATIVE
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Other individuals interviewed stated that bruising was not found on resident during assessments. The investigation concluded, based on interviews that the allegation was not proven to be true.

Based on LPA’s record review of IB’s report, the above allegations is determined to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

A copy of this report was left with Administrator along with appeal rights.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2