<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700585
Report Date: 12/02/2022
Date Signed: 12/30/2022 09:48:26 AM

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
09/09/2022 and conducted by Evaluator Renee Campbell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220909152751
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:
12/02/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Teresita Alomendehe, LicenseeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident being outside unattended
Unexplained Black Eye
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/02/22, License Programming Analyst (LPA) Renee Campbell made an unannounced visit to the Indocare 2 Facility at approximately 9:00 am. LPA was met by the Administrator and staff and explained the purpose of the visit. Employee timesheets from August and September of 2022 and the Personnel Report were reviewed. Review of R1’s 602 documented sundowning behaviors, the preplacement appraisal documents night supervision required. LPA reviewed the staffing schedule from August 2022, September 2022 and interviewed staff and the Administrator. The work schedule for all staff revealed there are no awake staff scheduled from 10 pm to 6 am. During that time, “staff are asleep and will only wake up if there is an emergency”, per the Administrator during an interview. S2 reported that she works in the facility most days. LPA asked if she had been present when R1 had wandered. S2 stated “Yes”. S2 explained that since staff were not awake at night, and would not have seen her get up or go out the door at night. LPA asked S2 if she had seen R1 get the black eye. S2 described finding blood in the bathroom one morning and a spot of blood on R1’s bed. S2 saw the black eye but no one witnessed how R1 got the black eye.

Based on LPAs observations, interviews, and record reviews, there is a preponderance of evidence to conclude that the facility does not have awake staff during sleeping hours as required and that R1 sustained unexplained injuries while in care due to lack of appropriate monitoring, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
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-20220909152751
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
HSC
1569.321(e)
1
2
3
4
5
6
7
1569.321(e) Every facility...shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety and well-being.
1
2
3
4
5
6
7
Licensee will audit all resident charts and current staffing schedules to ensure adequate monitoring and supervision of resident . Licensee will submit an audit to be completed by POC date.
8
9
10
11
12
13
14
Based on interviews and record reviews, the licensee did not meet the supervision needs of clients. This poses a potential Health, Safety or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type B
12/16/2022
Section Cited
CCR
87705(b)(4)
1
2
3
4
5
6
7
87705(b) Care of Persons with Dementia
(b) Licensees who retain residents with dementia ... shall have at least one night staff person awake and on duty if any resident with dementia is determined ... to require awake night supervision.
1
2
3
4
5
6
7
The Administrator and Licensee will read the regulation regarding this citation and write a statement that the regulation was read and understood. The Administrator shall email the statement to renee.campbell@dss.ca.gov by the close of business of the POC date.
8
9
10
11
12
13
14
Based on interviews and record reviews, the licensee did not meet the supervision needs of dementia clients in need. This poses a potential Health, Safety or Personal Rights risk to person in care.
8
9
10
11
12
13
14
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: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2