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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701059
Report Date: 04/11/2025
Date Signed: 04/29/2025 01:06:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
08/09/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240809112033
FACILITY NAME:AMAZING GRACE ELDER CARE #2FACILITY NUMBER:
342701059
ADMINISTRATOR:MATIAS, PATRICIAFACILITY TYPE:
740
ADDRESS:7723 EL RITO WAYTELEPHONE:
(916) 329-8745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rino De La CruzTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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1) Staff engaged in an inappropriate relationship with resident.
2) Staff are mismanaging resident's medication.
3) Staff did not keep resident's personal information confidential
4) Staff are not meeting resident's needs
5) Staff did not ensure the facility is kept clean.
6) Staff did not ensure the facility was free of rodents
7) residents are working as manintenance staff; moving the lawn, getting groceries, cutting a tree.
8) staff do not have appropriate training as required.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Amazing Grace Elderly Care II RCFE on DATE at TIME to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Staff, Rino De La Cruz and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA conducted an interview with the alleged vicim (R1), (see confidential names list, LIC 811 dated 4/11/25) in regards to staff having an inappropraite relationship with a staff member. R1 denied the allegation and stated they were just friends and got along well. LPA was unable to conduct a staff interview with the former staff member as the number on file is no longer in service. Staff interviewed denied witnessing or any knowlege of an inappropraite sexual relationship between any staff member and a resident at the faclility.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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 6
Control Number 27-AS-20240809112033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AMAZING GRACE ELDER CARE #2
FACILITY NUMBER: 342701059
VISIT DATE: 04/11/2025
NARRATIVE
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Regarding allegation that facility mismanaged a resident's medication, LPA reviewed medication administration records for all residents and conducted inventories of medications. LPA observed the medication administration records to be complete and documented. LPA did not observe any errors with medications. LPA reviewed staff files and observed all required training in place to meet regulations for the staff members present at the facility. LPA attempted to contact former staff member but was unable to conduct an interview with the former staff member. LPA was unable to corroborate the allegation.

Regarding allegation that resident information was not kept confidential, LPA observed in the facility that all client records are locked an inaccessible to clients in care. S1 and S2 denied any knowledge of listing in on a meeting with placement agency and facility. LPA attempted to interview former staff member but was unable to conduct an interview with the former staff member. LPA was unable to corroborate the allegation.

Regarding allegation that the facility was not meeting residents needs, LPA conducted interviews with six residents and all but the alleged victim denied the allegation. The alleged victim had minimal needs and services identified as R1 was independent with all ADLs, and continued to be active and drive in the community. LPA was unable to identify any unmet needs of residents in care as documented in the resident's appraisals and needs and services plan. LPA was unable to corroborate the allegation.

Regarding the allegations the facility was not kept clean and was not kept free of rodents. LPA conducted an annual inspection just prior to receiving the complaint and did not observe any evidence of rodents and observed the facility to meet the cleanliness standards established by the department. LPA also obtained records from the facility documenting the existing pest control that is utilized by the facility on an ongoing basis. LPA was presented with pictures of rodent droppings but was unable to confirm the location of the images as they were very close up and provided no indication they were actually from the facility. additionally, LPA was presented with a photo of a mouse captured in a trap which does indicate the facility was addressing the presence of rodents in and around the facility in a timely manner.

Regarding the allegation that alleged victim was working as maintenance staff LPA was unable to corroborate the allegation. Reporting party indicated R1 was paid $100 a month to perform these services which was denied by R1 and S1. R1 did indicate he wanted to help out around the facility and had a background in handiwork. Licensee denied requesting or demanding that R1 perform theses duties and denied any staff member would request R1 to perform such tasks.

Report Continued on LIC 9099-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240809112033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AMAZING GRACE ELDER CARE #2
FACILITY NUMBER: 342701059
VISIT DATE: 04/11/2025
NARRATIVE
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 The department does encourage activities for residents that may include such activities like gardening and outings. LPA observed R1 was independent with transportation and driving and there are no regulations that would prevent a resident on going on outings or purchase own food in addition to what is being supplied by the facility.

Finally, LPA reviewed staff records and observed all documented training for staff members present and met department regulations. LPA was unable to corroborate the allegation that staff were not adequately trained to meet resident needs.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of (indicate the complaint allegation) are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
08/09/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240809112033

FACILITY NAME:AMAZING GRACE ELDER CARE #2FACILITY NUMBER:
342701059
ADMINISTRATOR:MATIAS, PATRICIAFACILITY TYPE:
740
ADDRESS:7723 EL RITO WAYTELEPHONE:
(916) 329-8745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rino De La CruzTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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1) Unlawful Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Amazing Grace Elderly Care on 4/11/25 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Rino De La Cruz and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA reviewed the eviction notice and the statements included in the eviction notice are not consistent with reports provided to the department (note: the department has received no incident reports regarding conflict or failure to comply with house rules). Additionally, the department was not notified of the eviction notice within 5 days of the eviction notice being provided to the resident as required in section 87224. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Eviction/Discharge is substantiated.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240809112033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AMAZING GRACE ELDER CARE #2
FACILITY NUMBER: 342701059
VISIT DATE: 04/11/2025
NARRATIVE
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The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240809112033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AMAZING GRACE ELDER CARE #2
FACILITY NUMBER: 342701059
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/18/2025
Section Cited
CCR
87224(f)
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Eviction Procedures: A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by LPA and the department did not receive notification of the resident eviction within
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Licensee will provide a written plan of correction indicating the steps facility will make in the future to ensure that any future eviction will meet all department requirements. POC due date 4/18/25.
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 5 days of providing the notice to the resident wich poses a potential health, safety or personal rights 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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6