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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002823
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:33:49 PM

Substantiated


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
01/06/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250106143751
FACILITY NAME:WHOLESOME ELDERLY ON KIFISIAFACILITY NUMBER:
345002823
ADMINISTRATOR:FAAMAUSILI,CHRISFACILITY TYPE:
740
ADDRESS:6024 KIFISIA WAYTELEPHONE:
(916) 678-0268
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Juan Ramirez, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff are mismanaging residents' medications

Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood met with Administrator, Juan Ramirez, to deliver findings regarding the complaint allegations listed above.

During the course of the investigation, LPA conducted interviews, reviewed residents' medications, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Facility staff are mismanaging residents' medications

** Report continued on 9099-C **

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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 3
Control Number 59-AS-20250106143751
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: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823
VISIT DATE: 01/16/2025
NARRATIVE
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During visit conducted on 1/07/2025, LPA attempted to conduct a medication count. LPA observed that the facility is not documenting start dates to indicate when resident medications are started. LPA observed that they were unable to conduct a medication count of the residents' medications due to having insufficient information regarding medications. LPA also observed medications on cite for resident (R1) that did not have a doctor's order on file at the facility.

During visit conducted on 1/15/2025, LPA conducted a medication count for R1 using information documented at the facility. LPA observed inconsistencies between medications counted and what was documented at the facility. LPA observed medications and doctor's orders on cite for residents R1, R2, and R3 at the facility. LPA observed doctor's orders for medications for R1, R2, and R3 that were not on cite. LPA observed medications for R1 and R2 on cite that did not have doctor's order on file.

Allegation: Facility is in disrepair

During visit conducted on 1/07/2025, LPA observed the entryway in R1's bedroom contained a plastic mat. LPA felt underneath the mat and observed that carpet underneath the plastic mat was damp. LPA observed soiled pee pads in the cabinets underneath the kitchen sink. During visit conducted on 1/15/2025, LPA observed plastic mat removed from R1's bedroom entryway. LPA felt carpet where plastic mat was and observed that carpet in R1's bedroom was still damp. LPA observed underneath kitchen sink and observed soiled pee pads to be damp.

Based on medication review, LPA's observations, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. A civil penalty in the amount of $250 was assessed for today's date due to a repeat violation.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250106143751
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: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility will ensure that medications are being administered as prescribed. Facility will obtain medications that are missing on cite and doctor's orders for medications on cite. Facility will conduct an audit of medications bi-weekly for the next three months.
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Based on medication review and records reviewed, the facility did not ensure that residents were receiving all medications prescribed as needed, which poses an immediate health, safety, and personal rights risk to residents in care.
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Facility will complete a statement of understanding regarding regulation 87465 and submit statement to LPA by POC due date. A civil penalty assessment in the amount of $250 was assessed for today's date for a repeat violation.
Type B
01/31/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Facility will hire services to assess kitchen sink and treat carpets in resident's bedroom. Facility will submit proof of services to LPA by POC due date.
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Based on LPA's observations, staff did not ensure facility was in good repair when carpet was soiled in resident's bedroom and kitchen sink had soiled padding, which poses a potential health, safety, and 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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
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