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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701338
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:44:26 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
05/21/2024 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20240521234725
FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
342701338
ADMINISTRATOR:PARAMO, FERNANDO PAZFACILITY TYPE:
740
ADDRESS:8351 LANCRAFT DR.TELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 3DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Fernando ParamoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff caused an injury to a resident
Staff inappropriately touches the residents
Staff mishandled a resident
Staff does not properly feed a resident
INVESTIGATION FINDINGS:
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On 7/16/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to deliver the findings for a complaint received on 5/21/24. LPA met with Administrator Fernando Paramo and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on records review, and staff and resident interviews, there is insufficient evidence to substantiate the allegations mentioned above. Based on resident interviews, 3 out of 5 residents stated they do not have any injuries caused by staff. Residents stated that staff have never touches them inappropriately or handle them in a rough manner. Residents reported they are properly fed and have no concerns with care. Based on staff interviews, staff (S1) denied the allegations mentioned above, stating that he never touches any residents inappropriately or has caused any injuries to the residents.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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 2
Control Number 27-AS-20240521234725
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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 07/16/2024
NARRATIVE
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Moreover, residents and staff denied witnessing or knowing of any physical or verbal abuse taking place in the care home. The investigation revealed that resident (R1) is diagnosed of dementia and suffers from confusion, disorientation, and inappropriate behavior.

As a result of the investigation, LPA finds the allegation above to be 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 and a copy of the report was provided upon exit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2