Complaint Investigation Report
342700783-3-30-2026-59-AS-LMUZ-DT7UA7-20260416152416
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
02/13/2026 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20260213101436
Staff improperly transferred resident resulting in staff dropping resident.
On 3/30/26, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver complaint findings for allegations listed above. LPA and LPM met with administrator, Sevrena Miller during today's visit and explained the purpose of the visit.
The department conducted record review and interviewed residents and staff regarding the allegation. The investigation revealed that on 01/14/2026 resident, R1 sustained a fall during a transfer by staff, S1. A review of R1’s needs and service plan documents R1 requires a 2-person physical assist and notes “always use gait belt”. S1 attempted to transfer R1 without another staff or using a gait belt resulting in R1 falling and causing pain and injury.
Based on the information gathered, the preponderance of evidence standards has 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 LIC 9099-D page.
Exit interview conducted. Appeal rights and a copy of this report were provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction