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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317000496
Report Date: 10/03/2025
Date Signed: 10/06/2025 09:44:14 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
08/25/2025 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20250825153656
FACILITY NAME:C. SEISA HOUSE-STODDARDFACILITY NUMBER:
317000496
ADMINISTRATOR:BAGGETT, BRANDYFACILITY TYPE:
735
ADDRESS:317 STODDARD WAYTELEPHONE:
(530) 889-0737
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 0DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Custodio SeisaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner for a resident in care.
Staff are not properly managing residents P&I money.
Staff did not keep facility free of bed bugs.
Staff did not administer medications as prescribed.
INVESTIGATION FINDINGS:
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On October 3, 2025, Licensing Program Analyst (LPA) Cassandra Mikkelson attempted to contact the licensee via phone and sent an email to deliver final findings regarding a complaint that was received on August 25, 2025.

**Continued on 9099-C page**
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
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 7
Control Number 59-AS-20250825153656
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: C. SEISA HOUSE-STODDARD
FACILITY NUMBER: 317000496
VISIT DATE: 10/03/2025
NARRATIVE
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Staff did not seek medical attention in a timely manner for a resident in care.

Interviews conducted with staff and resident R1 indicated that Resident R1 had an incident while on an outing with staff that required medical attention. R1 did not receive medical attention until the following day after the incident occurred. Records reviewed indicated that R1 did have a fracture to their foot which required a cast. Therefore, the allegation staff did not seek medical attention in a timely manner for a resident is care is substantiated.

Staff are not properly managing residents P&I money

Records review indicated that Resident R1 and R2’s P&I money was inaccurate to the ledger. It was written on the ledger that money had been used but the count of the money indicated that the money had not been removed or used. Therefore, the allegation staff are not properly managing resident’s P&I money is substantiated.

Staff did not keep facility free of bed bugs

Records reviewed indicated that Resident R1 had bed bugs in their mattress and room belongings in May 2025. Facility indicated that a pest control company came out to spray for bed bugs. Facility is now free of bed bugs and is continuing to have maintenance spraying done to prevent further incidents. Therefore, the allegation staff did not keep facility free of bed bugs is substantiated.

Staff did not administer medications as prescribed.

Records reviewed indicated that medication for Resident R1 was not administered as prescribed. Documented reviewed indicated that R1’s medication had one pill missing from the package but it was not documented on the Medication Administration Record (MAR) that is was given to R1. There were also medication bottle and packs that were not written on the Centrally Stored Medication Record (CSMR) to indicate that the medication was received and when the medication had been started. Therefore, the allegation staff did not administer medications as prescribed is substantiated.

**Report on 9099-C2 page

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20250825153656
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: C. SEISA HOUSE-STODDARD
FACILITY NUMBER: 317000496
VISIT DATE: 10/03/2025
NARRATIVE
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Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D page. Appeal rights given.

Licensee was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The Licensee is to sign and return a copy to the Sacramento North Regional Office.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
08/25/2025 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20250825153656

FACILITY NAME:C. SEISA HOUSE-STODDARDFACILITY NUMBER:
317000496
ADMINISTRATOR:BAGGETT, BRANDYFACILITY TYPE:
735
ADDRESS:317 STODDARD WAYTELEPHONE:
(530) 889-0737
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 0DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Custodio SeisaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff placed plastic on top of a resident's bedding.
INVESTIGATION FINDINGS:
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On October 3, 2025, Licensing Program Analyst (LPA) Cassandra Mikkelson attempted to contact the licensee via phone and sent an email to deliver final findings regarding a complaint that was received on August 25, 2025.

Staff placed plastic on top of a resident's bedding.

Observations indicated that there was plastic on top of the resident’s mattress to prevent the spread of bed bugs. Interviews conducted indicated that there was no plastic placed on top of resident bedding but only on the mattress to help prevent spread of bed bugs. There is not enough evidence to indicate that plastic had been placed on resident’s bedding within the facility. Therefore, the allegation staff placed plastic on top of a resident’s bedding is unsubstantiated.

**Report continued on 9099-C page
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20250825153656
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: C. SEISA HOUSE-STODDARD
FACILITY NUMBER: 317000496
VISIT DATE: 10/03/2025
NARRATIVE
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Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Licensee was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The Licensee is to sign and return a copy to the Sacramento North Regional Office.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20250825153656
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: C. SEISA HOUSE-STODDARD
FACILITY NUMBER: 317000496
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2025
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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The licensee does not currently have any client’s in care therefore no plan of correction is due at this time.
Should the licensee accept a client/resident, the licensee shall notify the department within 24 hours of admission.
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This was not met by evidenced by: R1 sustained an injury to their left ankle. Medical attention was not received until the following day. This poses an immediate health and safety risk to clients in care.
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Type A
10/07/2025
Section Cited
CCR
80026(h)(1)
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80026 Safeguards for Cash Resources,Personal Property, and Valuables of Residents(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
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The licensee does not currently have any client’s in care therefore no plan of correction is due at this time.
Should the licensee accept a client/resident, the licensee shall notify the department within 24 hours of admission.
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This was not met by evidenced by: R1 and R2's ledgers did not match the current monies that R1 and R2 had at the facility.
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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: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20250825153656
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: C. SEISA HOUSE-STODDARD
FACILITY NUMBER: 317000496
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2025
Section Cited
HSC
80087(a)(1)
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80087 Buildings and Groundsv(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.
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The licensee does not currently have any client’s in care therefore no plan of correction is due at this time.
Should the licensee accept a client/resident, the licensee shall notify the department within 24 hours of admission.
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This was not met by evidenced by: Facility had an outbreak of bedbugs in May of 2025.
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Type A
10/07/2025
Section Cited
CCR
80075(k)(7)
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80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year(...)
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The licensee does not currently have any client’s in care therefore no plan of correction is due at this time.
Should the licensee accept a client/resident, the licensee shall notify the department within 24 hours of admission.
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This was not met by evidenced by: R1 and R2 had prescription medications at the facility that were not documented. R1 had 1 medication that had been given but no documentation was written of the dose,time or date.
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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: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7