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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700585
Report Date: 12/02/2022
Date Signed: 12/30/2022 09:50:43 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
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: DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Teresita Alomendehe, LicenseeTIME COMPLETED:
03:43 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to report changes to Responsible Party
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended report to correct the time listed above. LPA was at the facility from 9 am to 4 pm.
On 12/02/22, License Programming Analyst (LPA) Renee Campbell made an unannounced visit to the Indocare 2 Facility at approximately 9 am. LPA was met by Luisito Manalansan and Orpha Manalansan and later Lomendehe and explained the purpose of the visit to conduct an annual inspection and case management.

LPA conducted interviews with staff and clients. Incident Reports, care notes, hospital records and 602 were reviewed. There were five incidents of the client wandering that were recorded over a two year period and the client’s daughter or responsible party (RP) was notified each time. There were no other caregiver notes or incidents reports to confirm if there were any unreported events and the RP could not be reached to discuss the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated
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)
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