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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002918
Report Date: 10/01/2024
Date Signed: 11/06/2024 01:52:37 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
08/27/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240827132621
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: 3DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Ola Samuels, LicenseeTIME COMPLETED:
02:24 PM
ALLEGATION(S):
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Staff did not administer resident's medications as prescribed.
INVESTIGATION FINDINGS:
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Amend to make 'Public'- On October 1, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver complaint findings for complaint # 59-AS- 20240827132621. LPA met with Ola Samual, Administrator/Licensee, and informed her the reason for the visit.

The Department received a complaint alleging the facility staff did not administer resident's medications as prescribed.

LPA reviewed resident files and conducted interviews with residents and staff. LPA also obtained schedules and other documentation. LPA interviewed 2 staff and 1 resident. Licensee stated she accepted the resident that came from another facility in which the resident was taking a narcotics for relief of pain. Licensee states when she went to get a refill for the resident, the doctor would not refill the order of medication until the resident saw a local physician. Licensee was not able to have the prescription filled.

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

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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-20240827132621
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: 10/01/2024
NARRATIVE
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9099-C...
In an interview with the resident, the resident confirmed that the emergency room physician would not refill the prescription until the resident saw a primary care physician. The resident has since moved out of the facility. This agency has investigated the complaint alleging the facility staff did not administer resident’s medication as prescribed. Based on LPA's observations and interviews which were conducted and recorded, we have found that the complaint was unfounded, meaning, the allegation was false, could not have happened and/or is without a reasonable basis. Allegation unfounded.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted, and a copy of this report was given to Ola.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2