<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002902
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:13:13 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
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):
1
2
3
4
5
6
7
8
9
Staff withheld resident’s mail.
Staff disposed a residents belongings without permission.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 interviews.

Please continue to LIC 9099-C….
Substantiated
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 3
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegations: Staff withheld resident’s mail.-SUBSTANTIATED 
During an interview with caregivers, they indicated that when the facility receives mail for residents in care the caregivers put the mail on the Administrator’s desk. The administrator stated they sort out the mail for each resident and then give the residents their mail. Based on staff statements, it was revealed that staff had opened a package that R1 received in the mail at R1’s responsible party’s request.  The staff admitted they did not give R1 the package because R1 is not able to have the item inside, which was THC/CBD gummies.  

Based on LPAs interviews which were conducted, staff revealed that they have withheld R1’s mail. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited pursuant to California Code of Regulations, Title 22 and documented on the attached LIC9099D

Allegations: Staff disposed a residents belongings without permission.-SUBSTANTIATED
In an interview with staff, it was stated that R1 sometimes is sent items that they are not able to have, which was the THC/CBD gummies. Staff interview further revealed that they opened a package that was sent to R1. Upon opening the package, the staff did not give the item to the resident that was sent to them stating they did not want ants in the facility.  

Based on LPAs interviews which were conducted, staff revealed that they kept items from R1 that were sent to them. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited pursuant to California Code of Regulations, Title 22 and documented on the attached LIC9099D.  

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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
87468.1(a)(15)
1
2
3
4
5
6
7
87468.1(a)(15)
(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to come up with a policy to ensure all residents received their mail unopened and in a timely manner. Licensee will submit policy to LPA Ratajczak.
8
9
10
11
12
13
14
Based on interview, the licensee did not comply with the section cited above as R1 was not given mail that they received which poses a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
02/29/2024
Section Cited
CCR
87468.1(a)(3)
1
2
3
4
5
6
7
87468.1(a)(3)
(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to submit a statement of what rights resident do have as well as to have a staff training on resident rights by POC due date.
8
9
10
11
12
13
14
Based on interview, the licensee did not comply with the section cited above as R1 had received an item that was not given to them by staff which poses a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3