342701138-3-20-2023-27-AS-ECUL-CQ5S4T-20230321133312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701138
Report Date: 01/04/2023
Date Signed: 03/20/2023 08:29:42 AM

Unsubstantiated

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
10/11/2022 and conducted by Evaluator Renee Campbell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221011152900

FACILITY NAME:	COMFORTS OF HOME LAGUNA PARK		FACILITY NUMBER:	342701138
ADMINISTRATOR:	KANG, MARIA		FACILITY TYPE:	740
ADDRESS:	5721 LAGUNA PARK DRIVE		TELEPHONE:	(916) 833-1493
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Kang. Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff hit resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced visit to this facility to deliver investigation findings on 01/04/2023 at approximately 11:00 am. LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Maria Kang.

The investigation was conducted by the Department which consisted of reviews of the facility records and interviews with facility staff. The residents and other witnesses were contacted and interviewed. The complaint alleges that residents were hit by staff.

During the investigation, it was revealed that one witness (F1) stated they saw a resident being hit. Another witness testified no one was hit but was instead redirected. Only one resident was able to be questioned and they stated no one had hit them and that they liked the facility and
the staff. Records show that all staff have been cleared and received dementia training.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report was amended to reflect that it is PUBLIC access and it is unsubstantiated. Larry Caculitan has been given permission by the administrator to sign updated report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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-20221011152900

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: COMFORTS OF HOME LAGUNA PARK	FACILITY NUMBER: 342701138
	VISIT DATE: 01/04/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Due to conflicting accounts, the investigation revealed a lack of evidence to substantiate that residents were being hit while in care.
This Department has determined the complaint alleging the above allegation is 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.
Exit interview was conducted with Administrator Maria Kang and a copy of the report was provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2