<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920179
Report Date: 05/28/2026
Date Signed: 05/28/2026 02:55:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2026 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20260417113210

FACILITY NAME:NEW DEVOTION FAMILY CARE HOME LLCFACILITY NUMBER:
315920179
ADMINISTRATOR:BLAS, MEKISHAFACILITY TYPE:
735
ADDRESS:572 SILVER CLOUD CT.TELEPHONE:
(863) 205-4134
CITY:ROSEVILLESTATE:CAZIP CODE:
95747
CAPACITY:4CENSUS: 3DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shawnette Etheridge, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide resident with medical attention in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with administrator Shawnette Etheridge during today’s inspection.
LPA investigated allegation, “Staff did not provide resident with medical attention in a timely manner". LPA interviewed relevant party, staff and clients and reviewed documentation. Relevant party stated C1 was not feeling well and facility staff made C1 attend program that day. Relevant party reported when C1 was returning to the facility at the end of the day, C1 reported to bus driver that they were in pain. When C1 returned to the facility, bus driver reported to facility staff that C1 needed an ambulance and staff stated that C1 would not need an ambulance but they would take them to urgent care immediately. LPA interviewed administrator in which she reported that C1's family informed her that C1 needed to be seen by a doctor once C1 returned to the facility.

Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20260417113210
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: NEW DEVOTION FAMILY CARE HOME LLC
FACILITY NUMBER: 315920179
VISIT DATE: 05/28/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator stated she made an appointment at urgent care and had staff immediately take C1 to urgent care once C1 returned back to the facility. Administrator reported that bus driver yelled that an ambulance was needed, however C1 was walking and calm and so they took C1 directly to urgent care instead of calling 911. Once C1 was seen at urgent care, they were transferred to the hospital. C1 was later discharged with a diagnosis of the flu. No changes of care or medication changes occurred. Due to the information gathered, LPA finds allegation to be unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

Exit interview was conducted and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3