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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920286
Report Date: 04/30/2026
Date Signed: 04/30/2026 10:35:49 AM

Unfounded


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
02/06/2026 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20260206122928
FACILITY NAME:A1 SENIOR CARE 4FACILITY NUMBER:
315920286
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:201 STAR DREAM COURTTELEPHONE:
(279) 336-1702
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Daisyree Tacandong, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Providing a modified diet without a doctors order
Length of time between dinner and breakfast does not meet regulation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA spoke with administrator Daisyree Tacandong during today’s inspection.

LPA investigated allegation, “Providing a modified diet without a doctors order”. The department interviewed relevant parties, staff, and residents in care, and reviewed documentation. Interviews with relevant party indicated that administrator modified R1’s diet by giving them thickened liquids without the consent of the following primary care physician. Relevant party believes it negatively impacted R1’s health. LPA interviewed administrator, a registered nurse, in which she stated that they did start R1 on thickened liquids due to R1 choking when drinking thin liquids. Administrator stated that she was afraid R1 was going to have adverse health effects due to choking on liquids. A doctor appointment occurred in January 2026 and administrator asked for family to request a speech therapist before administrator could discontinue the thickened liquids.

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

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
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 5
Control Number 59-AS-20260206122928
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: A1 SENIOR CARE 4
FACILITY NUMBER: 315920286
VISIT DATE: 04/30/2026
NARRATIVE
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R1 was discharged from the facility prior to a therapist coming out to the facility. Administrator did not receive physician order to add thickener to R1’s liquids, but administrator was working in her scope of practice, and a physician order is not required to add thickener to resident’s water. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, “Length of time between dinner and breakfast does not meet regulation”. The department interviewed relevant party, administrator, and current residents in the facility. Relevant party indicated that dinner was being served at 3 PM, and no food or liquid was provided to residents until the following morning. Administrator stated that breakfast is served around 7-7:30 AM, Lunch around 11:30 AM and dinner around 4:30- 5 PM, and snacks are available and served throughout the day and evening. LPA interviewed caregiver who stated the same timeline. LPA interviewed 1 current resident, and they stated breakfast is served around 7:15 AM, Lunch around 11:30 AM and dinner was served around 4:30-5 PM. Resident stated there is sufficient food, and snacks served throughout the day. LPA toured the kitchen area and observed 2-day perishable and 7-day non-perishable amount of food. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of report provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/06/2026 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20260206122928

FACILITY NAME:A1 SENIOR CARE 4FACILITY NUMBER:
315920286
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:201 STAR DREAM COURTTELEPHONE:
(279) 336-1702
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Daisyree Tacandong, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA spoke with administrator Daisyree Tacandong during today’s inspection.
LPA investigated allegation, “Insufficient staffing”. The department interviewed relevant parties, administrator, staff, and reviewed documentation. The department interviewed relevant party in which she stated that prior to admission administrator stated there would always be 2 caregivers in the home 24 hours. Relevant party stated that R1 needed a 2-person transfer due to the use of a hoyer lift, and R1’s care needs. LPA interviewed administrator and other caregivers in which she stated there is 2 caregivers from 7 AM to 12 PM, 1 caregiver from 12-4 PM, 2 caregivers from 4-7 PM, and then 1 caregiver from 7 PM to 7 AM. LPA reviewed facility documentation in which the pre-placement assessment states R1 is assisted by two-persons with transfers and mobility using a hoyer lift. R1’s needs and service plan states, “She also needs two-persons assist with her transfers and mobility using a hoyer lift.” Due to the information gathered Administrator did not ensure there were 2 caregivers available to R1 in order to meet their individual needs. LPA finds allegation to be SUBSTANTIATED. Deficiencies cited on 9099-D. Copy of report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Citations on this Visit Report are Under Appeal!

Control Number 59-AS-20260206122928
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: A1 SENIOR CARE 4
FACILITY NUMBER: 315920286
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
05/08/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Administrator to send LPA a statement of understanding that the facility will be staffed according to resident's care needs. Statement to be sent into CCL by 5/8/26.
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This requirement is not met as evidenced by: Based on interviews and record review the licensee did not provide sufficient staffing for R1 which poses/posed a potential health, safety or personal rights risk to persons 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: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
02/06/2026 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20260206122928

FACILITY NAME:A1 SENIOR CARE 4FACILITY NUMBER:
315920286
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:201 STAR DREAM COURTTELEPHONE:
(279) 336-1702
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Daisyree Tacandong, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Neglect resulting in unstageable wound
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA spoke with Administrator Daisyree Tacandong during today’s inspection.
LPA investigated allegation, “Neglect resulting in unstageable wound.” The department interviewed relevant parties, administrator, staff, and reviewed documentation. The department interviewed relevant party in which they stated R1 developed a pressure injury due to lack of proper repositioning and inconsistent brief changes. R1 moved out of the facility in February 2026 and relevant party stated they never saw the injury in person and R1 did not receive medical attention for the wound and was not taken to see a doctor while they had the pressure injury. LPA interviewed administrator in which she stated R1 moved into the facility in October 2025 and was receiving home health services but was discharged in December 2025. R1 had redness on their coccyx but there was no pressure injury. Administrator stated R1 was very fragile with sensitive skin and they repositioned R1 every 2 hours to prevent pressure injuries. LPA interviewed caregiver in which they stated they repositioned R1 every 2 hours and changed them frequently for continence care. 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5