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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700079
Report Date: 12/28/2023
Date Signed: 12/28/2023 11:22:16 AM

Unsubstantiated


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
10/24/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20231024152049
FACILITY NAME:RETREAT AT ROYAL GREEN LLC, THEFACILITY NUMBER:
342700079
ADMINISTRATOR:TIN, ANTONETTEFACILITY TYPE:
740
ADDRESS:865 ROYAL GREEN AVENUETELEPHONE:
(916) 549-2724
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 0DATE:
12/28/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Antonette TinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Other: Licensee does not ensure appropriate accommodations for staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Retreat at Royal Green on 12/28/23 at 11:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be corroborated. This facility is currently not accepting residents and have not been operating with any residents or staff members for approximately 6 months. LPA was unable to interview any current staff members at this facility. LPA conducted collateral interviews with four staff members from other licensed facilities operated by the licensee. Staff interviews did not corroborate the allegations and all staff interviewed denied the facility allowed staff members to sleep while on duty at the facility and no facility plan of operation reviewed by LPA indicated overnight sleeping arrangements or designated staff sleeping rooms. The licensee denied the allegations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
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 2
Control Number 27-AS-20231024152049
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: RETREAT AT ROYAL GREEN LLC, THE
FACILITY NUMBER: 342700079
VISIT DATE: 12/28/2023
NARRATIVE
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Additionally, The allegations are alleged to have occurred over 5 years ago and the staff members have not been employed by the facility for 5 years. LPA was unable to obtain any documentation regarding the staff members as the files have been purged as they were over three years old.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2