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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002823
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:24:12 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
01/13/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250113131500
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:
03/06/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Juan Ramirez, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff are not assisting residents with ADLs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Juan Ramirez, to deliver findings into the complaint allegation listed above.

During investigation, LPA conducted a tour of the care home, conducted interviews, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff are not assisting residents with ADLs

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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-20250113131500
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: 03/06/2025
NARRATIVE
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Relevant party reported that the facility staff are not providing assistance with activities of daily living (ADLs) for residents, including showering and incontinence care.

LPA reviewed records on the premises for residents R1, R2, R3, R4, and R5, including medical assessments, appraisals, and needs and services plans. LPA observed inconsistencies amongst records reviewed. R1's appraisal dated 7/23/2024 indicated that R1 needs assistance with transferring, dressing, bathing, hair care, personal hygiene, incontinence care, and supervision moving about the facility. R1's medical assessment dated 4/17/2024 indicated that R1 does not have bowel or bladder impairment, is confused but able to communicate their own needs, and is able to bathe, dress, groom, feed, and toilet themselves. R2's appraisal dated 8/26/2022 indicates R2 does not use a wheelchair. LPA observed during multiple visits that R2 uses a wheelchair. R2's appraisal indicates R2 does not need assistance with transferring, bathing, hair care, hygiene, moving about the facility, or incontinence. R2's medical assessment dated 6/3/2022 indicates R2 has bladder and bowel impairment and needs assistance with bathing.

Interview with staff member (S1) indicated that staff member (S2) was not providing proper assistance with R5 regarding showers. R5's medical assessment dated 9/29/2022 indicates that R5 needs assistance with bathing and dressing. Interview with S2 indicated that they were unaware that R1 was incontinent or needed incontinence care. Interview with staff member (S3) indicated that no residents at the facility are incontinent. S3 stated that they don't help R5 with showers and they don't assist with resident showers "at all." S3 stated that they were told to remind residents to take a shower. LPA determines that, with the inconsistencies amongst residents records and staff statements, residents are not receiving sufficient assistance with ADLs.

Based on LPA's observations, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

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: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250113131500
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: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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Facility will updated all resident assessments, appraisals, and needs and services plans. Facility will also conduct an in-service training for all staff regarding updated assessments. Facility will submit updated assessments and proof of training by POC due date of 4/7/2025.
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Based on LPA's observations, interviews conducted, and records reviewed, the facility did not ensure to provide proper assistance with ADLs for residents, 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: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
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