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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700735
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:08:13 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
01/19/2023 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20230119171903
FACILITY NAME:PALM VALLEY CARE IFACILITY NUMBER:
342700735
ADMINISTRATOR:ANGELITA DAYOANFACILITY TYPE:
740
ADDRESS:8700 MILO COURTTELEPHONE:
(916) 686-2128
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
03/29/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Angelita Padua DayoanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident is not allowed to leave the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) arrived unannounced to conclude the complaint investigation on 3/29/23 at 12:00pm. LPA met with Administrator Angelita Padua Dayoan and stated the purpose of the visit.

On 1/19/23, Community Care Licensing received a complaint alleging “Resident is not allowed to leave the facility”. An interview of staff, administrator, residents, private caregiver, and Power of Attorney revealed that resident #1 (R1) was not trying to leave the facility with anyone. However, during the move-in period, becoming acclimated to the facility, R1 in a confused state, did attempt to leave and was redirected back to the facility for safety. LPA obtained information that residents residing in the home are allowed to use the facility phone and receive visitors. LPA reviewed the Durable Power of Attorney (POA) documents for R1 which gives authority to cover healthcare decisions and financial affairs. The Provider Information Notice 21-48-ASC (PIN) that is provided to licensees as guidance indicates that POA’s typically do not address issues concerning visitation, telephone calls, or personal mail and therefore, agents are not authorized to restrict these rights.
Unfounded
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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 2
Control Number 27-AS-20230119171903
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: PALM VALLEY CARE I
FACILITY NUMBER: 342700735
VISIT DATE: 03/29/2023
NARRATIVE
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However, a POA agent can regulate these only if the resident explicitly gave the authority to do so and the principal does not disagree with the choices the agent is making.

During the investigation, LPA also observed that there is not a restraining order in effect to not allow visitation, calls or mail for R1.

Additionally, LPA obtained information that R1 has been receiving calls at the facility although the personal cell phone was removed by the POA due to phone company issues.

Since becoming familiar with the facility, R1 has not attempted or indicated a wish to leave the facility for any reason. Visits and outings are occurring.

Based on the investigation and a review of documentation the allegation is deemed UNFOUNDED. The preponderance of evidence standards has not been met.

“This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Div 6, Ch 8, no violations cited during this visit. Exit interview conducted copy given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2