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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 032701486
Report Date: 07/25/2025
Date Signed: 07/25/2025 04:13:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2025 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20250722140900
FACILITY NAME:LIVEWELL CARE HOME LLCFACILITY NUMBER:
032701486
ADMINISTRATOR:KAREN ORRFACILITY TYPE:
735
ADDRESS:290 GOLD STRIKE CTTELEPHONE:
(302) 893-3498
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY:4CENSUS: 4DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jonathan LiTIME COMPLETED:
03:47 PM
ALLEGATION(S):
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Facility staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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On 7/25/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived unannounced at this facility to conduct the initial complaint visit regarding the allegation noted above. LPA met with the Licensee Jonathan Li (S1) and stated the purpose of the visit. Present during this visit were 4 clients in care with 3 staff on duty.

The investigation into the above allegation consisted of interviews and record reviews.

An interview with S1 confirmed that staff did not administer resident's medication as precribed. S1 also stated that current staff received verbal training relating to following medication administration procedure to include adherence to what was prescribed.
Per review of the incident report submitted to the Department on 7/22/2025, it was noted that resident (R1) has been receiving their medication after meals and not as prescribed which is one hour before meals.

{Con't 9099-C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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 3
Control Number 27-AS-20250722140900
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LIVEWELL CARE HOME LLC
FACILITY NUMBER: 032701486
VISIT DATE: 07/25/2025
NARRATIVE
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Based on the review of R1’s After Visit Summary from their doctor on 4/1/2025, the medication (M1) has the following order: Take one Tablet by mouth daily on an empty stomach 1 hour before eating. Do not combine with other medications or supplements.

Per review of R1's medication (M1), this medication should be taken on tablet by mouth on an empty stomach 1 hour before eating. It also states that this medication should not be combine with other medications or supplements.

Based on interviews and record reviews, the allegation that facility staff did not administer resident's medication as prescribed is SUBSTANTIATED. A finding that is substantiated means that the allegations are valid because the preponderance of the standard has been met.

Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Plan of corrections were discussed.
An exit interview was conducted with S1 and a copy of this report and appeal rights were provided to facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20250722140900
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIVEWELL CARE HOME LLC
FACILITY NUMBER: 032701486
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
07/26/2025
Section Cited
CCR
80075(b)
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80075 Health Related Services(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by:
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Per discussion, Licensee completed a verbal in-service training with current staff regarding assisting with medication administration.
LIcensee agreed to submit the proof of in-service training by POC due date.
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Based on interviews and records review, the licensee did not ensure staff followed medication orders for Resident (R1), which poses a potential health, safety, and personal rights risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3