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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920177
Report Date: 08/18/2026
Date Signed: 08/18/2026 11:08:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
08/13/2026 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260813162226
FACILITY NAME:A&C ELDERLY CARE HOMEFACILITY NUMBER:
315920177
ADMINISTRATOR:ION, CARMENFACILITY TYPE:
740
ADDRESS:4120 SECRET RAVINE WAYTELEPHONE:
(916) 223-5435
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 6DATE:
08/18/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Carmen IonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident eloped from facility due to insufficient door alarms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday August 18, 2026, unannounced to conduct a complaint visit regarding the above allegation. LPA met with Administrator Carmen and explained the purpose of the visit.

LPA interviewed the Administrator regarding the allegation. LPA learned the following: On Monday, August 10, 2026, staff were doing morning rounds at approximately 6:30am and could not locate R1. Staff previously observed R1 sleeping at approximately 2:30am. Staff then called the Administrator who arrived at the facility. The administrator called R1's POA to assist with locating them. Police were notified and assisted with the search. R1 was located sitting on the porch at a neighboring house at approximately 9:20am. R1 was then escorted back to the facility. Per R1's physicians report, Resident (R1) is not able to leave the facility unassisted due to a diagnosis of dementia.

continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
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 59-AS-20260813162226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: A&C ELDERLY CARE HOME
FACILITY NUMBER: 315920177
VISIT DATE: 08/18/2026
NARRATIVE
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Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D.


Exit interview. Copy of report and appeal rights provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20260813162226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: A&C ELDERLY CARE HOME
FACILITY NUMBER: 315920177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2026
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia.
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement was not met as evidenced by: Based on interview conducted and
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Licensee now uses a whole house alarm to alert staff when doors are opened. Additionally, a floor alarm was placed in R1's hallway to alert staff if they are exiting their hallway. This citation is cleared at the time of the complaint visit.
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documentation reviewed, the Licensee did not ensure that door alarms were loud enough for staff to hear when residents exit, which posed an immediate health and safety risk 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.
SUPERVISOR'S NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3