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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002549
Report Date: 08/12/2022
Date Signed: 08/12/2022 02:22:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220607143656
FACILITY NAME:AFABLE HOME CARE IIFACILITY NUMBER:
347002549
ADMINISTRATOR:AFABLE, NICOLASA O.FACILITY TYPE:
740
ADDRESS:4080 PALM AVENUETELEPHONE:
(916) 258-3737
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY:6CENSUS: 5DATE:
08/12/2022
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Nicolasa O. Afable, LicenseeTIME COMPLETED:
02:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not releasing records to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility and met with Licensee, Nicolasa Afable, to deliver findings into the allegation listed above. Facility staff wore masks while on the premises.

During investigation, the Department reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility is not releasing records to resident.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
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 25-AS-20220607143656
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AFABLE HOME CARE II
FACILITY NUMBER: 347002549
VISIT DATE: 08/12/2022
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
The Department obtained a copy of request for resident’s (R1’s) documents dated 6/8/2022 on behalf of R1 via relevant party. The Department obtained a death certificate for R1 indicating that R1 passed away on 4/11/2022. The Department reviewed R1’s Identification and Emergency Information to verify R1’s responsible party. The Department obtained a copy of Authorization to Handle Claim indicating R1’s responsible party as giving permission to relevant party to request R1’s records.

With written consent from R1’s responsible party, the Department is requesting the facility to release R1’s records to relevant party via records request generated on 6/8/2022.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Licensee's signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20220607143656
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AFABLE HOME CARE II
FACILITY NUMBER: 347002549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
87506(c)(1)
1
2
3
4
5
6
7
87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) (…) The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will release R1’s records via request from relevant party and submit proof of submission to Department. Facility will review regulation 87506 and complete a statement of understanding to Department. Facility will submit proof of submission and statement of understanding to Department by POC due date by 8/26/2022.
8
9
10
11
12
13
14
Based on records reviewed, the facility did not ensure that resident R1’s records were made available via request by relevant party with authorization of R1’s responsible party, which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3