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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002902
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:07:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2022 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 25-AS-20221014082654
FACILITY NAME:UNITY MEMORY HOME CAREFACILITY NUMBER:
345002902
ADMINISTRATOR:LIU, YINGFACILITY TYPE:
740
ADDRESS:8161 CHIMANGO COURTTELEPHONE:
(916) 301-8792
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 4DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ying Liu (Ruby) TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff pushed resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program manager (LPM) Laura Munoz arrived at the facility unannounced on 10/19/22 to do the complaint investigation for above allegation. LPA and LPM met with administrator Ying Liu (Ruby) and explained the purpose of the visit. Prior to the visit , LPA and LPM completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA and LPM wore the following Personal Protective Equipment (PPE) during today's visit-surgical masks. LPA and LPM were screened by facility staff upon entry.

The department conducted records review ,observations and interviews.


**Report continued on LIC9099-C**


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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 25-AS-20221014082654
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: UNITY MEMORY HOME CARE
FACILITY NUMBER: 345002902
VISIT DATE: 10/19/2022
NARRATIVE
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** continued from 9099--------

Based on interviews conducted, there was an incident with R1 and licensee wherein licensee took R1's medications from R1 as the licensee had the understanding that R1's medications needed to be centrally stored. R1's physician provided documentation to the licensee that R1 is capability of managing own medication and as of today's date, the licensee returned R1's medications back to her. There is inconsistencies as to what actually occurred during the incident therefore the allegation of 'Staff pushed resident in care' is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 and a copy of this report was provided to the facility.
The signature of the Administrator on these forms acknowledges receipt of these documents.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2