019200305-11-21-2025-15-AS-BFOG-DP8UQP-20251210144727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200305
Report Date: 11/21/2025
Date Signed: 11/21/2025 03:12:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2025 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20250225094642

FACILITY NAME:	REDWOOD HOME AT NILES GROVE		FACILITY NUMBER:	019200305
ADMINISTRATOR:	EDITH SARMIENTO		FACILITY TYPE:	735
ADDRESS:	35537 NILES BLVD		TELEPHONE:	(510) 818-0720
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	6	CENSUS: 6	DATE:	11/21/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Edith Sarmento, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff assaulted client with a gun
Staff handled client in a rough manner
Staff did not follow reporting requirements
Staff did not provide a safe environment for client
Staff did not provide adequate food service to client
Staff did not provide adequate care and supervision resulting in client eloping several times
Staff did not ensure that client's bed was maintained in good repair
Staff retaliated against client
Staff isolated client
Staff falsified client records

INVESTIGATION FINDINGS:

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On 11/21/25 at 1:45PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Edith Sarmento, Administrator and explained the purpose of the visit.

During the course of the investigation, the Department obtained and reviewed the facility staff schedule, the LIC 500 Personnel Report, and pertinent documents from Client 7’s (C7) file. Documents reviewed included but were not limited to: Identification and Emergency Information; Pre-Placement Appraisal Information dated 7/1/2021; Physician’s Report dated 9/7/2023 indicating C7 exhibits “occasional” confusion and can bathe, dress, and toilet independently; and the Functional Capability Assessment dated 7/1/2021, which states that C7 communicates verbally with “some limitations.” The Regional Center of the East Bay Individual Program Plan (IPP) Update dated 5/21/2024 was also reviewed.

Report continues on LIC 9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

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 8

Control Number 15-AS-20250225094642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE	FACILITY NUMBER: 019200305
	VISIT DATE: 11/21/2025

NARRATIVE

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The Department further requested and reviewed the Fremont Police Department Report #24-711003. As part of the investigation, interviews were conducted with the assigned police detective, facility staff, the party (RP) responsible, and clients. Reports show that there is no evidence of S2 assaulting C7.

Allegation: Staff assaulted the client with a gun

Finding: Unsubstantiated

Investigation:
On 4/29/2025 at approximately 10 AM, the Department interviewed former Redwood Home resident Client 7 (C7) at 30262 Oakbrook Road, Hayward, CA 94544. C7 alleged that, on one occasion, Staff 2 (S2) tied C7 to a dining room chair, restrained C7’s hands behind C7’s back, taped C7’s mouth, and threatened C7 with a firearm.

The Department conducted interviews with 10 facility staff. No staff reported witnessing the alleged incident, and all staff stated they had never observed S2 behave in an assaultive or threatening manner toward residents. S2 denied the allegation and denied possessing or owning a firearm. S2 reported that, at times, C7 would act out things C& sees in movies. C7 would always role-play and want S2 to role-play with C7. C7 would ask S2 to pretend to hold S2's fingers and play pretend. However, S2 believed C7 may have misinterpreted this role-play scenario. No corroborating evidence was obtained to support the allegation.

Report continues on LIC 9099c1...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250225094642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE	FACILITY NUMBER: 019200305
	VISIT DATE: 11/21/2025

NARRATIVE

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On 2/26/25 the Department interviewed C2 and C5 with both reporting having no knowledge or observation of staff mistreating the residents. C5 stated are “so nice” and are always with the clients. C2 expressed that C7 “wants attention” and fabricates stories to get both staff and residents “in trouble.” Both C2 and C5 stated that C7 yells at staff. And has a history of “causing trouble.” On 2/26/25, 2/27/25, and 2/28/25 LPA attempted to contact C2 and C7 Case manger.

Finding:
Based on the information obtained and the absence of corroborating evidence, the allegation that S2 tied and threatened C7 with a firearm is unsubstantiated.

Allegation: Staff did not follow reporting requirements

Finding: Unsubstantiated

Based on the investigation, which included interviews, review of facility records, and review of reporting documentation, the allegation that staff failed to follow required reporting procedures is unsubstantiated. Although the concern was reported, there is insufficient evidence to determine that staff did not meet mandated reporting requirements. No corroborating documentation or statements were obtained to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Report Continues on LIC 9099c2...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 15-AS-20250225094642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE	FACILITY NUMBER: 019200305
	VISIT DATE: 11/21/2025

NARRATIVE

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Allegation: Staff handled client in a rough manner

Finding: Unsubstantiated

Based on the investigation, which included 10 staff interviews/ 3 clients, observations, and review of available documentation, the allegation that staff handled a client in a rough manner is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm that staff engaged in improper or rough physical handling. Statements obtained during the investigation were inconsistent, and no corroborating evidence was found to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation: Staff did not provide a safe environment for the client

Finding: Unsubstantiated

In June of 2024, C7 disclosed that client 2 (C2) touched and licked C7's penis and buttocks while at the facility. In the months before the disclosure, C7 did not report to staff or family any interactions with C2 related to unwanted sexual behaviors. The disclosure was made after C7 was removed from the facility. C2 adamantly denied inappropriately touching and sexually assaulting C7. C2 felt that C7 “wanted attention” and made false claims against C2. On 5/20/25, the department interviewed 10 Staff members, who reported no concerns regarding C2 displaying inappropriate behaviors. The department reviewed the C2 file, which included no history of sexually deviant behaviors.

Report Continues on LIC 9099c3...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 15-AS-20250225094642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE	FACILITY NUMBER: 019200305
	VISIT DATE: 11/21/2025

NARRATIVE

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RP reported that C7’s mental and physical health began to deteriorate around October 2023. RP attributes the deterioration to the abuse that C7 endured a former facility. Several elopements and behavioral issues exhibited by C7 were documented; however, when interviewed, 10 staff members. 10 out of 10 stated C7 always has staff that follow C7 when C7 leaves the facility. Some incident reports, which were obtained, corroborate C7’s dislike for C2. RP made multiple efforts to request that C7 and C2 be separated and that both residents undergo group therapy to mitigate further issues.

In March of 2024, C2 threw a remote control at C7 and hit C7 on the lower back. No incident report or other documentation was obtained for this incident; however, the incident was corroborated by staff, and C2 admitted to the act. C2 stated that C2 was upset that C7 was bothering C2. C2 recalled that two staff members, Unknown and S4, were on duty at the time. S4 stated S4 did not see the remote hit C7; however, witness C2 threw the remote out of frustration.

When asked what the facility did to mitigate issues between C7 and C2, Administrator (ADM) Edith Sarmiento pointed to the facility increasing C7’s appointments with the facility’s behaviorists and ensuring C7 attended psych appointments. Additionally, ADM stated that the facility was unable to move C2 to a different room because C2’s family would not agree to a move. Based on the information obtained, there is insufficient evidence to support this allegation; therefore, the allegation is unsubstantiated.

Report continues on LIC 9099c4...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 15-AS-20250225094642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE	FACILITY NUMBER: 019200305
	VISIT DATE: 11/21/2025

NARRATIVE

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Allegation: Staff did not provide adequate food service to client

Finding: Unsubstantiated

Based on the investigation, which included interviews, observations, and review of meal service records, the allegation that staff failed to provide adequate food service to a client is unsubstantiated. Although the concern was reported, there is insufficient evidence to determine that the client was not provided appropriate or sufficient meals. Statements obtained during the investigation were inconsistent, and no documentation or observations substantiated the claim. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation: Staff did not provide adequate care and supervision resulting in client eloping several times

Based on the investigation, which included interviews of 10 staff, review of supervision logs, incident reports, and other relevant documentation, the allegation that staff failed to provide adequate care and supervision, resulting in the client eloping several times, is unsubstantiated. Although the concern was reported, there is insufficient evidence to determine that staff did not provide the required level of supervision. Documentation and statements obtained during the investigation did not corroborate the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Report continues on LIC 9099c5...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 15-AS-20250225094642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE	FACILITY NUMBER: 019200305
	VISIT DATE: 11/21/2025

NARRATIVE

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Allegation: Staff did not ensure that client's bed was maintained in good repair

Finding: Unsubstantiated

Based on the investigation, which included interviews, observations of client’s bedroom, and review of facility maintenance records, the allegation that staff failed to ensure the client’s bed was maintained in good repair is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm that the bed was in disrepair or that staff failed to address any maintenance needs. No corroborating documentation or consistent statements were obtained to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation: Staff retaliated against client

Finding: Unsubstantiated

Based on the investigation, which included 10 staff interviews and 3 clients , review of facility records, and other relevant documentation, the allegation that staff retaliated against the client is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm that staff engaged in retaliatory actions. Statements obtained were inconsistent, and no corroborating evidence was found to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Report Continues on LIC 9099c6...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 15-AS-20250225094642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD HOME AT NILES GROVE	FACILITY NUMBER: 019200305
	VISIT DATE: 11/21/2025

NARRATIVE

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Allegation: Staff isolated client

Finding: Unsubstantiated

Based on the investigation, which included 10 staff interviews and 3 clients, observations, and review of relevant facility documentation, the allegation that staff isolated the client is unsubstantiated. Although the concern was reported, there is insufficient evidence to determine that staff engaged in isolating practices. Statements obtained during the investigation were inconsistent, and no corroborating documentation or observations supported the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation: Staff falsified client records

Finding: Unsubstantiated

Based on the investigation, which included interviews, review of client records, and examination of facility documentation, the allegation that staff falsified client records is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm that any documentation was intentionally altered or falsified by staff. Records reviewed were consistent with staff statements, and no corroborating evidence was obtained to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Finding:

Based on the Department's observations, interviews conducted, records reviewed, and investigation, this allegation is found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with the Administrator. A copy of the report was given.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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