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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317001368
Report Date: 10/14/2025
Date Signed: 10/14/2025 11:43:42 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
06/27/2025 and conducted by Evaluator Cassandra Mikkelson
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250627111725
FACILITY NAME:THREE PINES ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
317001368
ADMINISTRATOR:SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:1450 OAK RIDGE WAYTELEPHONE:
(530) 885-5181
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 0DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Custodio "Joel" SeisaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident was injured by staff
Staff handled client in a rough manner
INVESTIGATION FINDINGS:
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On October 14, 2025, Licensing Program Analyst (LPA) Cassandra Mikkelson attempted to contact the licensee via phone and email to deliver final findings regarding a complaint that was received on June 27,2025

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

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 3
Control Number 59-AS-20250627111725
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: THREE PINES ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 317001368
VISIT DATE: 10/14/2025
NARRATIVE
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Resident was injured by staff

Interviews conducted with Client C1 and Licensee indicated that C1 received bruises on their arm and shoulder during an altercation with Licensee on 06/19/2025. Observations indicated that there was bruising on C1’s arm and shoulder after the incident occurred. Based on the reported information, the allegation that resident was injured by staff is substantiated.

Staff handled client in a rough manner

Interviews conducted with Client C1 indicated that the bruising on their arm was a result of being hit by Licensee. Interviews conducted with Licensee indicated that they had hit C1 an unknown number of times during an incident that occurred on 06/19/2025. Observations indicated bruising that was on C1’s arms and shoulders after the incident had occurred. Therefore, the allegation staff handled client in a rough manner is substantiated.

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.

Deficiency 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: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250627111725
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: THREE PINES ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 317001368
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1)To be accorded dignity in his/her personal relationships with staff and other persons.
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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: Client C1 received bruises during an incident involving Licensee on 06/29/2025.
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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: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3