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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005155
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:51:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
09/20/2024 and conducted by Evaluator Holly Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240920154553
FACILITY NAME:ALOHA ASSISTED LIVINGFACILITY NUMBER:
347005155
ADMINISTRATOR:GRACE F. DULAYFACILITY TYPE:
740
ADDRESS:7816 TIGERWOODS DRIVETELEPHONE:
(916) 647-9331
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:4CENSUS: 4DATE:
09/23/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Grace DulayTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are serving residents expired foods
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open this complaint investigation. LPA Moleski and Williams met with facility administrator Grace Dulay and explained the purpose of the visit.

This investigation consisted of observation and interviews with staff and residents.

LPA Williams interviewed Dulay and two residents (R1-R2). Dulay said that she tries to label all of the facility's food with the date the food item was opened. LPAs Moleski and Williams observed many items which were labeled with dates within the current month, but also some items which were labeled with a future date. Other items were not labeled. Dulay said that she checks all of her food every week before garbage day. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
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 27-AS-20240920154553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALOHA ASSISTED LIVING
FACILITY NUMBER: 347005155
VISIT DATE: 09/23/2024
NARRATIVE
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While touring the facility, Dulay said that the refrigerator in the garage contained her food and the refrigerator in the kitchen contained the residents' food. LPA Williams observed in the refrigerator in the kitchen several expired products. In the kitchen, LPA Moleski observed an onion sprouting, and another purple vegetable sprouting multiple shoots. These items were stored alongside several other vegetables. Dulay threw the purple vegetable away during this visit.

Items which were observed to be expired in the residents' refrigerator and pantry included: apple sauce packets expired 7/20/24, caesar salad expired 9/19/24, potato salad expired 8/24/24, whipping cream expired 8/27/24, street corn dip expired 7/13/24, sour cream expired 7/24, pork loin riblets expired 11/16/18, dragon fruit expired 5/16/24, Dinamita sticks expired 7/30/24, prunes expired 6/24, holiday mini baking chips expired 10/29/2022, and spaghetti expired 2/25/24.

The department has determined the following as it relates to the allegation that staff is serving residents expired food:

Based on interviews and observations, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87555(b)(9). An exit interview was held with Dulay. Appeal rights and a copy of this report were left with Dulay.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240920154553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALOHA ASSISTED LIVING
FACILITY NUMBER: 347005155
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2024
Section Cited
CCR
87555(b)(9)
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87555 General Food Service Requirements
"(b) The following food service requirements shall apply:
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service."

This requirement was not met as evidenced by:
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Licensee agrees to remove all expired food from facility, keep only resident food in the refrigerator in the kitchen, write a plan for storage and labeling of food in refrigerator and pantry. Licensee further agrees to send LPA Williams photos of the refrigerator after cleaning and to send the written plan by POC due date.
holly.williams@dss.ca.gov
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Based on observation and interview of Dulay, LPAs Moleski and Williams found many expired foods in the resident refrigerator, which poses an immediate health, safety and/or personal rights risk.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC9099 (FAS) - (06/04)
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