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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700843
Report Date: 08/10/2023
Date Signed: 08/10/2023 04:56:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
07/10/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230710160617
FACILITY NAME:PADUA ASSISTED LIVING 2FACILITY NUMBER:
342700843
ADMINISTRATOR:DAYOAN, ANGELITAFACILITY TYPE:
740
ADDRESS:2929 BABSON DRIVETELEPHONE:
(279) 333-7621
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Angelita DayoanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not properly supervising residents in care resulting in residents wandering from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with administrator Angelita Dayoan and explained the purpose of the visit.

This investigation consisted of interviews with Dayoan, staff members (S1-S3), residents (R1-R4), R1’s sibling, R1’s independent living specialist, and R1’s Alta California Regional Center (ACRC) service coordinator, review of resident records, and review of facility records.

In interviews, Dayoan, S1, and S3 described an incident in which R2 left the facility unaccompanied. Dayoan said R1 turned off the alarm on a door leading outside from R1’s bedroom, which allowed R2 to leave without being noticed. Dayoan said this incident occurred on July 10, 2023. Dayoan said R2 was gone for five or 10 minutes before staff noticed R2 was gone. S1 said R2 walked about a block and was gone for about 30 minutes before staff noticed. S3 said the alarm on R1’s exterior door sometimes does not work, and that R2 left through this door without staff noticing. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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 4
Control Number 27-AS-20230710160617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PADUA ASSISTED LIVING 2
FACILITY NUMBER: 342700843
VISIT DATE: 08/10/2023
NARRATIVE
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R1 said R1 has turned off the alarm on this door. Dayoan, S1, S2, and S3 said R2 sometimes tries to leave the facility to go to church. R2 said R2 goes to church alone. R2’s LIC 602 indicates that R2 cannot leave the facility unassisted.

In interviews, Dayoan said she did not know where R1 was discharged after being hospitalized. Dayoan said R1 was discharged on July 2, 2023. Dayoan could not provide any discharge paperwork from this hospital visit. Dayoan said R1 was hospitalized after leaving the facility without authorization and asking a neighbor to call emergency services. R1’s sibling said they unintentionally ran into R1 on the street around this time. R1 corroborated the sibling’s account of their run-in on the street. R1’s sibling said R1 was not accompanied by staff at the time. R1 said that after being discharged from the hospital, R1 was given a bus pass. R1 said R1 stayed at a friend’s house for one night, and spent multiple other days living on the street. R1’s ACRC service coordinator said ACRC was notified of R1’s general whereabouts by R1’s sibling after their contact with R1. Dayoan said R1 returned to the facility after being discharged a second time from a different hospital. LPA Moleski reviewed discharge paperwork from this hospital dated July 5, 2023 which show R1 was returned to Dayoan’s facility. R1’s LIC 602 indicates that R1 cannot leave the facility unassisted. R1’s ACRC service coordinator said ACRC has received calls from other community members notifying ACRC that R1 was out in the community.

LPA Moleski reviewed a handwritten statement written by S2. In this statement, S2 described an incident that occurred on July 11, 2023, around 5 p.m. S2 wrote that S2 was out walking with R1 when R1 got onto a bus. S2 wrote that S2 did not have bus fare. R1 left on the bus unaccompanied, according to S2’s statement. R1 corroborated the events described in S2’s statement. Dayoan said she filed a missing person report with the local police department after this incident. LPA Moleski reviewed a missing person report regarding R1 dated July 11, 2023. Dayoan said R1 was returned to the facility that same day, around 10 p.m. R1 said R1 called Dayoan and was picked up that same day, around 10 p.m.

The department has determined the following as it relates to the allegation that staff are not properly supervising residents in care resulting in residents wandering from the facility:

[continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20230710160617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PADUA ASSISTED LIVING 2
FACILITY NUMBER: 342700843
VISIT DATE: 08/10/2023
NARRATIVE
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Based on interviews with Dayoan, S1, S3, R1, R2, R1’s sibling, and R1’s ACRC service coordinator, and based on review of resident records and facility records, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87411(a). An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230710160617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING 2
FACILITY NUMBER: 342700843
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2023
Section Cited
CCR
87411(a)
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Personnel Requirements - 22 CCR Section 87411(a): "Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services."

This requirement was not met as evidenced by:
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Licensee agrees to send a written plan stating how staff will maintain supervision over residents as required to LPA Moleski by the POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews and document review, R1 and R2 were permitted to leave the facility without assistance, which poses an immediate health and safety risk.
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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: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4