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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002918
Report Date: 05/07/2024
Date Signed: 05/07/2024 11:12:19 AM

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
01/10/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240110112043
FACILITY NAME:ADONAI CARES FOR ELDERLYFACILITY NUMBER:
345002918
ADMINISTRATOR:SAMUELS, OLAWUMIFACILITY TYPE:
740
ADDRESS:5532 HONOR PARKWAYTELEPHONE:
(310) 272-3318
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:6CENSUS: 2DATE:
05/07/2024
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Ola Samuels, LicenseeTIME COMPLETED:
12:07 PM
ALLEGATION(S):
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Staff increased resident rent with a proper notice
Untrained staff
Staff overcharged resident
INVESTIGATION FINDINGS:
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On May 7, 2024, Licensing Program Analyst (LPA), DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 59-AS-20240110112043. Met with Ola Samuels, administrator/licensee, and informed her the reason for the visit.

Sacramento North Regional Office received a complaint alleging staff increased resident rent without prior notice, untrained staff and staff overcharged resident.

Based on interviews and records reviewed, the facility increased R1’s monthly rate from $4,000 to $6,000 without cause. According to R1’s Admission Agreement, it was agreed between the license and R1 that R1’s monthly fee would be $4,000 a month. In October 2023, the licensee provided R1 a notice indicating R1 needed a higher level of care than what the facility could provide. Upon issuing the notice, the licensee increased R1’s monthly fee to $6,000 a month effective December 1, 2023.

To continue see 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
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-20240110112043
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: ADONAI CARES FOR ELDERLY
FACILITY NUMBER: 345002918
VISIT DATE: 05/07/2024
NARRATIVE
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9099-C...
Based on a review of R1's records, R1 did not have a change in condition between the time R1 was admitted to the facility and when R1 received the notice of the increase. Additionally, R1 indicated they felt pressured to sign the admission agreement modification as R1 made the licensee at the time R1 was admitted that they were unable to pay more than $4,000 a month. The licensee did not supply adequate reasoning for the increase based on R1's change in condition therefore the increase was unlawful. Interviews indicated that S1 was assigned to assist R1 with transferring. It was reported that on two different occasions, S1 dropped R1 while transferring from the bed to the wheelchair and from the wheelchair to the bed.

Interviews indicated that incident occurred because S1 was not trained on proper transferring. Additionally, a review of S1's file indicated no training documentation. After R1's second fall, S1 was terminated from her employment at the facility.

On December 18, 2023, R1 went to the hospital for knee surgery and never returned to the facility. R1 was admitted to another facility from the hospital beginning January 1, 2024. From January 1, 2024 to January 2, 2024, the licensee charged R1 a fee of $1,000 a day until RP came to pick up personal belongings. Based on a review of the admission agreement signed on by both the licensee and R1, there is no language that permits the licensee to charge R1 this fee.

Based on LPA's observations and interviews which were conducted and recorded, the preponderance of evidence standards has been met, therefore, the allegations that staff increased resident rent with a proper notice, untrained staff, and staff overcharged resident to be SUBSTANTIATED.


Plan Of Correction for overcharging – repay the money to the resident and provide proof of payment.

Deficiencies are being cited on D Page.

To continue see 9099-D...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240110112043
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: ADONAI CARES FOR ELDERLY
FACILITY NUMBER: 345002918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/07/2024
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities.
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff,
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Licensee shall write on how it is important to be accorded dignity in personal relationships with staff, residents and other people.

Shall be submitted no LPA no later than June 7, 2024.
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residents, and other persons.
This was not done by facility intimidating R1 into signing an admission agreement modification for a rent increase.
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Deficiency Dismissed
Type A
05/07/2024
Section Cited
CCR
87411
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… The licensing agency may require any facility to provide additional staff whenever it determines
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Licensee shall have facility personnel at all times to be sufficient in numbers and competent to provide the services necessary to meet residents needs.
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through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.This was not done by having 1 staff working at the time of the incident.
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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: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
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