Complaint Investigation Report

342700185-2-4-2026-27-AS-LKIG-DS9KQA-20260317080602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO SOUTH ASC , 9835 GOETHE ROAD, SUITE 100

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

10/15/2025 and conducted by Evaluator Noel Wolf Petersen

COMPLAINT CONTROL NUMBER: 27-AS-20251015124111

Staff allowed clients in care to leave the facility without proper supervision

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a complaint investigation into the above allegations. LPA met with administrator monica butay and explained the purpose of the visit.

Interviewed 3 clients and 3 staff. Per administrator, s1 is an on call staff, s2 left more than 2 years ago and everyone else is a permanent employee of this facility, nobody other than s1 is sharing hours at another facility. Per record review, s1 and s2 are both on the gaurdian roster, s1 is on the current staff schedule. S2 may have been used as an on-call staff in the past 4 months. Per record review of the Staff files, S1 and S2 both have up to date, trainings, health screenings, first aid training from 2025. Clients are all reporting that they are not left alone, Staff are all indicating they understand the policy regarding awol and minimum staffing ratios, and how to call out if necessary. One client is expressing that it is unfair that there are so many staff, when other clients at her day program only have 2 or 3 staff.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A copy of the report was read and given to the staff. Appeal rights were provided. exit interview was conducted.