Complaint Investigation Report

342700588-2-20-2026-59-AS-LMUZ-DSFU6W-20260323151902

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO NORTH ASC , 9835 GOETHE ROAD, SUITE 100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

01/20/2026 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20260120092359

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Administrator, Placida Devera, to deliver complaint investigation findings regarding the above stated allegation.

On January 28, 2026, LPA observed that the doorknob on resident (R1's) door had a lock on the outside of the door. LPA also observed that R1's window had a nail in it preventing the window from opening. Interviews with the Administrator and staff (S1) indicated that R1 removes the door alarms and is exit seeking. Interviews also indicated that locking R1 in their room at night was due to safety concerns from R1's exit seeking behaviors. During the visit, the Administrator and S1 removed the nail in the window and changed the doorknob on the door to a knob without a lock. On February 20, 2026, LPA was informed that R1 has moved out of the care home.

Based on observations and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of the report and appeal rights provided.