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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700053
Report Date: 07/01/2025
Date Signed: 08/12/2025 11:50:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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 Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20250627115253
FACILITY NAME:FILLON HOMEFACILITY NUMBER:
342700053
ADMINISTRATOR:FILLON, BETTY JEANNEFACILITY TYPE:
735
ADDRESS:10351 FRANK GREG WAYTELEPHONE:
(916) 478-4074
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:4CENSUS: 4DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jeanne Fillon, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident is not being accorded dignity in their personal relationships with staff.
INVESTIGATION FINDINGS:
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This is an amended report from 07/01/2025.

On 07/01/2025, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced regarding a new complaint. LPA Campbell met with Jeanne Fillon and Rocelyn Fillon and explained the purpose of the visit.
LPA Campbell interviewed Licensee Jeanne Fillon and had both parties fill out a Declaration statement regarding the events of November 12th, 2024. Over the course of the visit. The Licensees confirmed that 2 staff reported to them that S1 applied alcohol to R1’s open wound when R1 refused to stop their behaviors. When S2 arrived during the visit, they too filled out a declaration statement regarding what they observed during the incident. When confronted with this accusation in November of 2024, S1 did not deny it and was asked to resign by the licensees.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 27-AS-20250627115253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FILLON HOME
FACILITY NUMBER: 342700053
VISIT DATE: 07/01/2025
NARRATIVE
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LPA Campbell reiterated with the licensees the importance of reporting any unusual incidents to the Department, discussed Personal Rights and corporal punishment, why S1's actions were unhealthy and the importance of continual review of Title 22.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiency is cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left with Betty Jeanne Fillon.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250627115253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FILLON HOME
FACILITY NUMBER: 342700053
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2025
Section Cited
CCR
80072(a)(3)
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Personal Rights.(a)…each client shall have personal rights which include, but are not limited to, the following: (3)To be free from corporal or unusual punishment, infliction of pain, humiliation, ... threat, mental abuse, or other actions of a punitive nature…This requirement was not met as evidenced by:
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Licensee will conduct an in-service training regarding personal rights and abuse. The signed staff attendance list will be sent to LPA Campbell to ensure completed staff training on resident rights including but not limited to: Elements of Section 80072. by POC due date to renee.campbell@dss.ca.gov
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Based on interviews and record reviews, facility staff engaged in utilizing punitive measures on residents due to behavior. This poses an immediate health, safety, or personal rights risk to residents in care.
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Deficiency Dismissed
Type B
07/11/2025
Section Cited
CCR
80061(d)
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80061(d) Any suspected physical abuse that does not result in serious bodily injury of an... dependent adult shall be reported to the local ombudsman, the ... licensing agency, and . local law enforcement agency within ... (24) hours. This requirement was not met as evidenced by:
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Licensees will provide a statement of understanding for regulation 80061(d) to LPA Campbell to be emailed to renee.campbell@dss.ca.gov
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Based on interviews and by the licensees own admission, no incident report was submitted to the Department on 11/12/24 because the physical abuse did not result in serious injury and staff resigned which poses 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: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
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