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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700606
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:17:31 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
02/16/2023 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230216101319
FACILITY NAME:LAND PARK PLACEFACILITY NUMBER:
342700606
ADMINISTRATOR:LUCAS, YACUBFACILITY TYPE:
740
ADDRESS:6140 S LAND PARK DRIVETELEPHONE:
(916) 395-7773
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 4DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH: Verny RoringTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not provide a care plan for resident upon admissions
Staff did not replace resident's smoke alarm.
Facility kitchen floor is in disrepair.
Facility ceiling has water damage.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigations of the above-mentioned allegations. LPA met with caregiver Verny Roring and stated the purpose for today's visit.

Regarding allegation, “Staff did not replace resident's smoke alarm”, through interviews, LPA obtained information that the smoke detector was not functioning properly during the time the resident resided in the room. Licensee stated the detectors’ battery was replaced only not hard wired until after the resident relocated. LPA received confirmation from City Fire Department that the detector is functioning properly in accordance with Fire Code which was checked once they received a complaint in February. Although, the detector is now working properly it was not correctly installed while resident was residing in the facility.

Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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-20230216101319
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: LAND PARK PLACE
FACILITY NUMBER: 342700606
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87203
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Fire Safety:
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Licensee replaced the smoke detector’s battery and connected the hard wire after the resident relocated.
You are hereby assessed an Immediate civil penalty in the amount of $150.00.

Plan of Correction cleared prior to visit.
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This requirement is not met as evidenced by: The Licensee stated to LPA that the battery was changed but not hard wired until later.
Based on Licensee did not ensure the smoke detector was working properly during the time resident resided in the home.
This poses an immediate health and safety risk to residents in care.
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Type A
05/17/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation
The facility shall be…in good repair at all times...for the safety and well-being of residents, employees and visitors
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Licensee shall submit a plan with a due date of when the ceiling and/or roof will be completely fixed along with a mold inspection.

Plan of Correction cleared prior to visit.
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This requirement is not met as evidenced by: The ceiling has visible spots.
Based on Licensee did not fix the ceiling and/or roof as there appear to be water damage. This poses an immediate health and safety risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230216101319
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: LAND PARK PLACE
FACILITY NUMBER: 342700606
VISIT DATE: 05/17/2023
NARRATIVE
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Regarding allegation, “Facility ceiling has water damage” through interviews and observation, LPA found that there are spots in the ceiling of one of the residents rooms that appears to be water damage.
Regarding allegation, “Staff did not provide a care plan for resident upon admission”, LPA obtained information that resident #1 (R1) and/or R1’s Responsible Party signed documents that were incomplete upon admission. Administrator stated that an assessment would be put into place after getting to know the resident. LPA observed the Admission Agreement that shows areas highlighted for signatures and initials, all of which are completed and signed by Licensee and Responsible Party on 2/5/23. However, the Identification and Emergency Information form (LIC601) was not completed, dated or signed. Additionally, Appraisal/Needs and Services Plan (LIC625) was observed to be incomplete but signed and dated which confirms the allegation.

Regarding allegation, “Facility kitchen floor is in disrepair”, through interviews and observation, Administrator and staff all confirmed that the kitchen floor was not leveled, and the laminate tiles were not properly attached to the floor which was a tripping hazard.

Based on interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. Additionally, Based on fire clearance deficiency not corrected prior to resident relocating, you are hereby assessed an Immediate civil penalty in the amount of $150.00.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview conducted and report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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
02/16/2023 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230216101319

FACILITY NAME:LAND PARK PLACEFACILITY NUMBER:
342700606
ADMINISTRATOR:LUCAS, YACUBFACILITY TYPE:
740
ADDRESS:6140 S LAND PARK DRIVETELEPHONE:
(916) 395-7773
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 4DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH: Verny RoringTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff are not following doctor's orders for resident.
Staff are not properly cleaning and sanitizing resident's room.
INVESTIGATION FINDINGS:
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Regarding allegation, “Staff are not following doctor's orders for resident”, during interviews LPA found that R1 was receiving exercises above and beyond what was recommended, and the resident kept a log. LPA obtained conflicting interviews regarding how much or when the exercises were provided as the care plan only stated daily.
Regarding allegation, “Staff are not properly cleaning and sanitizing resident's room”, during physical plant tour, LPA did not observe spots on the walls or the ceiling in resident #1’s room. The room has not been repainted. LPA did not obtain sufficient evidence that the room was not properly cleaned and sanitized prior to resident moving into the facility.
The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found 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. Per CCR (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20230216101319
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: LAND PARK PLACE
FACILITY NUMBER: 342700606
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited
CCR
8007(b)
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87506(a)(b)(1-17)(A-F) Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Each resident’s record shall contain at least the following information:
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Licensee shall submit a letter stating all required documents will be completed timely. To be submitted by Plan of Correction due date via fax.
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This requirement is not met as evidenced by: The required documents were not completed timely.
Based on Licensee did not ensure resident records were completed prior to signature and/or admittance.
This poses a potential health and safety risk to residents in care.
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Type B
05/19/2023
Section Cited
CCR
87303(a)(1)
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Maintenance and Operation
…Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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Licensee replaced the kitchen floor tiles to level out the floor.

Plan of Correction cleared prior to visit.
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This requirement is not met as evidenced by: Administrator stated the kitchen floor was not leveled, and the laminate tiles were not properly attached to the floor Based on Licensee did not ensure the floor was repaired timely for resident safety
This poses a potential health and safety risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5