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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700585
Report Date: 06/09/2021
Date Signed: 06/09/2021 04:05:38 PM

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
05/10/2021 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210510105518
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: 6DATE:
06/09/2021
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Orpha Manalansan, lead caregiverTIME COMPLETED:
04:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff struck a resident

Facility staff rough handles resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 not present but gave permission via phone to LPA for Orpha Manalasan to hear and sign the findings presented today. LPA informed Administrator and lead caregiver of the purpose for this visit. LPA provided findings regarding the allegation listed above. The investigation was conducted and consisted of reviews of resident records and other facility records. Interviews with facility Administrator, 3 staff members, and 3 residents was also conducted.
The complaint alleges that a staff member struck and rough handled a resident. The investigation concluded, based on interviews and record reviews that there is not a preponderance of evidence to conclude the allegations are true. Therefore, the allegations that a resident was struck and rough handled are UNSUBSTANTIATED.

A copy of this report was left with lead caregiver, Orpha along with appeal rights.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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