315920292-4-28-2026-59-AS-TORZ-DTRNTZ-20260504104534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315920292
Report Date: 04/28/2026
Date Signed: 04/28/2026 03:07:13 PM

Unfounded

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
03/02/2026 and conducted by Evaluator Graham Gunby

COMPLAINT CONTROL NUMBER: 59-AS-20260302095048

FACILITY NAME:	VISTA ROSEVILLE SENIOR LIVING		FACILITY NUMBER:	315920292
ADMINISTRATOR:	KIMBRO, SHERI		FACILITY TYPE:	740
ADDRESS:	100 STERLING COURT		TELEPHONE:	(916) 786-7200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	128	CENSUS: 88	DATE:	04/28/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Executive Director - Nathan Condie		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff neglect resulting in wound deterioration
Facility staff are not meeting resident's incontinence care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 04/28/2026 to complete and deliver findings to a complaint received on 03/02/2026. LPA met with Executive Director, Nathan Condie and explained the purpose of the visit.

Throughout the course of the investigation, the department conducted interviews and record reviews.

Please continue to LIC9099C..

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260302095048

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: VISTA ROSEVILLE SENIOR LIVING	FACILITY NUMBER: 315920292
	VISIT DATE: 04/28/2026

NARRATIVE

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Allegation: Facility staff neglect resulting in wound deterioration

During the course of the investigation, interviews were conducted as well as records reviewed. Interviews indicated that R1 was transferred from a Skilled Nursing Facility with a pressure injury near their lower back. S1 and F1 both confirmed R1 was receiving care from a home health agency that lacked communication. With the help of the facility, R1 transferred to a new home health agency that is able to provide the necessary care needed for R1. R1 confirmed their health has improved while at the facility and has no problems with the care they are currently receiving from the facility or home health.

Allegation: Facility staff are not meeting resident's incontinence care needs

An interview conducted with R1 revealed R1 does get assistance whenever needed. R1 emphasizes the satisfaction of the care staff and feels safe living at the facility. Interview conducted with F1 revealed that R1 feels comfortable at the facility and gets assistance with changing and toileting. R1 denied any lack of care and supervision. F1 and F2 expressed their concern for the previous home health agency as there was little to no communication, but is happy with the new agency. Interview conducted with F2 revealed that the care at the facility is amazing and that they receive full assistance with activities of daily living.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and report provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC9099 (FAS) - (06/04)

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