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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002902
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:12:03 PM

Unfounded


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
11/28/2023 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20231128082121
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:
02/15/2024
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Administrator- Ruby LiuTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not meet resident’s medical needs.
INVESTIGATION FINDINGS:
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On 02/15/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings Community Care Licensing (CCL) received on 11/28/23. LPA met with Administrator Ruby Liu and explained the purpose of the visit.

During the course of this investigation, the Department conducted a file review and interviews.

Please continue to LIC 9099-C….

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
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 59-AS-20231128082121
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: UNITY MEMORY HOME CARE
FACILITY NUMBER: 345002902
VISIT DATE: 02/15/2024
NARRATIVE
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Allegation: Staff did not meet resident’s medical needs.- Unfounded

On 11/25/2023 at 6:00 A.M., R1 sustained a fall near their bedroom door. Staff contacted emergency services immediately for medical attention. Emergency personnel assessed R1 and advised them to go to the hospital to seek further medical attention. However, R1 had refused transport. On 11/26/24 at 4:21 A.M, R1 had an unwitnessed fall at the facility in their room. R1 called 911 themselves instead of calling for a caregiver for assistance. Emergency personnel came to the facility to assist R1 up as well as assess. Emergency services advised R1 to go to the hospital for further medical attention and R1 refused transport. Both times when R1 had a fall, they had refused to seek further medical attention.

Based on information obtained through file review and interviews, the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of the report and appeal rights were left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2