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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002929
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:01:38 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
10/18/2023 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20231018154926
FACILITY NAME:DEAN ESTATEFACILITY NUMBER:
345002929
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5214 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Kassie HowellTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee admitted resident without a medical assessment signed by a physician within one year
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived uannounced to open and deliver the finding of the allegation listed above. LPAs met with Assistant Administrator Kassie Howell, and explained the purpose of the visit.

This investigation, LPAs conducted file review and interviews for the following allegation.

Results are as follow.

Please see LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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 5
Control Number 59-AS-20231018154926
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: DEAN ESTATE
FACILITY NUMBER: 345002929
VISIT DATE: 10/19/2023
NARRATIVE
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Allegation: Licensee admitted resident without a medical assessment signed by a physician within one year.

The Department conducted interview and file review. Based on interview with S1, it revealed facility was licensed October 2022. Based on file review, LPA observed facility to be licensed on 10/25/2022. Additionally, based on file review, it revealed R1 was admitted to the facility with a medical assessment-
LIC 602A PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) signed and dated 08/24/2022. File review revealed R1 was admitted to facility with a medical assessment that is within a year. The following allegation is unfounded.

UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and a copy of the report and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
10/18/2023 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20231018154926

FACILITY NAME:DEAN ESTATEFACILITY NUMBER:
345002929
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5214 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Kassie HowellTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee prohibited resident from having phone calls
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived uannounced to open and deliver the finding of the allegation listed above. LPAs met with Assistant Administrator Kassie Howell, and explained the purpose of the visit.

This investigation, LPAs conducted file review and interviews for the following allegation.

Results are as follow.

Please see LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20231018154926
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: DEAN ESTATE
FACILITY NUMBER: 345002929
VISIT DATE: 10/19/2023
NARRATIVE
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Allegation: Licensee prohibited resident from having phone calls.

The Department conducted interviews with S1 and S2 regarding this matter. Interview with S1 on 4/21/2023, it revealed that S1 has contacted Power of Attorney(s) prior to allowing R1 speak on the phone with other individuals, due to safety reasons. Interview revealed S1 is unsure if R1 is able to speak to others without Power of Attorney's approval. Based on interview with S2 on 10/6/2023, it revealed S2 confirmed to have inform family members that S2 will need to speak to R1's Power of Attorney frist before letting family members speak to R1. Based on file review, it revealed R1's Power of Attorney does not have limitation of visitations.

The allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following allegation cited above is substantiated, please see LIC9099-D.

Exit interview conducted, and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20231018154926
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: DEAN ESTATE
FACILITY NUMBER: 345002929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations... This requirement is not met as evidenced by:
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Licensee will submit a statement of compliance to the following regulation cited. Provide POC to LPA by 10/27/2023 via email.
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Based on interviews, Licensee did not comply with the section cited above as S1 and S2 informed LPA they contacted R1's Power of Attorney prior to allowing R1 talk on the phone with R1's family members which poses a potential risk for residents in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5