Complaint Investigation Report

392701388-11-17-2025-27-AS-LRIS-DNQPGV-20251124101900

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

06/04/2025 and conducted by Evaluator Kesha Lewis

COMPLAINT CONTROL NUMBER: 27-AS-20250604161942

Facility failed to supervise resdients resulting in sexual assault.

Facility failed to meet residents needs resulting in multiple falls and broken shoulder.

On11-17-2025, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver findings for the complaint allegations noted above. LPA met with Administrator Rachelle Reyes and explained the purpose of the visit.

Allegation 1 Facility failed to supervise residents resulting in sexual assault

The department investigated the above allegation and determined the allegation to be UNFOUNDED based on interview with the R1 who denies the allegation occurred. Also, multiple staff interviews who did not report concerning behaviors between R1 and R2. Also, R2 had no recollection of who R1 was.

Allegation 2 Facility failed to meet residents’ needs resulting in multiple falls and broken shoulder. The department investigated the above allegation and determined the allegation to be UNFOUNDED. According to the allegation received, R# sustained multiple falls resulting in a broken shoulder however, during the course of the investigation it was determined resident R3 sustained a fracture which was located on her tibia. Therefore, the allegation is UNFOUNDED.

Note that an unfounded finding means that the allegation is false, could not have happened, and/or is without a reasonable basis.