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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700782
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:24:53 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2024 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20241010122227
FACILITY NAME:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Staff, Sevrena MillerTIME COMPLETED:
12:40 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff sexually assaulted resident.
Staff did not treat resident with dignity and respect.
Staff spoke to resident in an inappropriate manner.
Staff handled resident in a rough manner.
Staff did not assist resident with care needs in a timely manner.
INVESTIGATION FINDINGS:
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2
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5
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9
10
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12
13
On 11/07/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Staff, Sevrena Miller to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival.

The department conducted records review ,facility observations and interviews to investigate the complaint.



**Report continued on LIC9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 4
Control Number 59-AS-20241010122227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: 7121 MAIN, LLC
FACILITY NUMBER: 342700782
VISIT DATE: 11/07/2024
NARRATIVE
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**report continued from 9099.....
Allegation- Staff sexually assaulted resident. Unfounded- The Department conducted six (6) residents and three (3) staff interviews to investigate this allegation. Resident, R1 disclosed in their interviews with Department that they were NOT sexually abused by staff at the facility. R1 stated that staff were not gentle with them while providing care to them but that was not sexual abuse in any manner. Three (3) Staff interviews and six (6) resident’s interviews indicated that they had no information about any sexual abuse to any residents. Based on this information, this allegation was found to be UNFOUNDED.

Allegation - Staff did not treat resident with dignity and respect. Staff spoke to resident in an inappropriate manner. Staff handled resident in a rough manner.- UNFOUNDED -The Department conducted six (6) residents and three (3) staff interviews to investigate these allegations. The Department interviewed three (3) staff and six (6) residents during complaint investigation visit on 10/23/24. Interviews did not indicate any residents, staff and/or witness observed that staff are not providing privacy to residents in care. Department observed during facility tour on 10/23/24 that facility staff were attentive to resident’s needs and providing them privacy while taking care of them and during resident’s personal time with families and visitors. During residents’ interviews, residents stated that facility staff are meeting their care needs and did not express any concerns with privacy or dignity. Residents’ interviews indicated that staff were treating all residents with dignity and respect and did not express any issues. Five out of six resident’s interviews indicated their satisfaction with staff’s professionalism and did not express any issue with staff were being rough with their care or speaking to them in any inappropriate manner. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED.

Allegation- Staff did not assist resident with care needs in a timely manner. -UNFOUNDED- The department conducted three (3) staff and six (6) residents' interviews, reviewed records to investigate the allegation. During residents’ interview, residents stated that staff respond in a timely manner, however sometimes there is a delay in response due to staff assisting other resident’s needs. Interviews and record review indicated that resident’s ADL’s which includes residents showering, incontinence and care needs are met as required and documented accordingly. Five (5) out of six (6) Residents’ interviews indicated that staff were providing care in a professional manner and their care needs were met and did not express any concerns. Three (3) staff interviews indicated that there were no issues with staffing and staff were assisting with all residents needs in timely way without any problems. Based on this information, this allegation is found to be UNFOUNDED.

Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2024 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20241010122227

FACILITY NAME:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Staff, Sevrena MillerTIME COMPLETED:
12:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not adequately assist resident with showering, resulting in a fall.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/07/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Staff, Sevrena Miller to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival.

The department conducted records review ,facility observations and interviews to investigate the complaint.



**Report continued on LIC9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20241010122227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: 7121 MAIN, LLC
FACILITY NUMBER: 342700782
VISIT DATE: 11/07/2024
NARRATIVE
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**report continued from 9099-A......

Allegation- Staff did not adequately assist resident with showering, resulting in a fall. -UNSUBSTANTIATED

The department conducted record review and interviewed staff and residents to investigate this allegation. Resident, R1 indicated that they had a fall on 09/20/24 when they were getting shower and staff were assisting them. R1 stated that they been sent to hospital after that fall incident and they hurt their back . Staff interviews indicated that R1 had a fall in the shower room on 09/20/24 when staff were helping R1 with shower and R1 fell as R1 attempted to stand up with sidebar but could not hold their body weight and slid on floor with staff’s assistance. After the fall incident, staff called the Emergency services and was transferred to local hospital to get medical treatment. Record review indicated that facility reported this fall incident to Department as required. From gathered information, it has been concluded that although, R1 had a fall incident in the shower room on 09/20/24, it was not due to lack of care and supervision of the facility and facility took appropriate measures to address R1s health issues after the fall incident. Based on this information, this allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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.


Exit interview conducted. Copy of the report provided.




SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4