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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700136
Report Date: 10/28/2025
Date Signed: 10/28/2025 04:21:23 PM

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
02/05/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250205110855
FACILITY NAME:HARVEY ESTATEFACILITY NUMBER:
342700136
ADMINISTRATOR:KHAN, HANIFFACILITY TYPE:
735
ADDRESS:9812 HARVEY ROADTELEPHONE:
(209) 329-5689
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:4CENSUS: 4DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Brittney ChavesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff restrained resident
Staff dropped resident
Staff left residents in soiled clothing/linens
Facility stove in disrepair
Facility was out of ratio
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with house manager Brittney Chaves and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed 10 staff members. All clients of this facility are nonverbal.

During a site visit on 2/13/25, LPA Moleski observed the facility stove to be working and in good repair. No staff members interviewed were aware of any issues with the facility stove.

During that same visit, LPA Moleski acquired one year’s worth of incident reports, staff schedules and time card reports, resident medication administration records (MARs), and daily care notes. These documents comprised the entirey of the year of 2022, which is the time frame provided by the complainant regarding these allegations. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
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 5
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
02/05/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250205110855

FACILITY NAME:HARVEY ESTATEFACILITY NUMBER:
342700136
ADMINISTRATOR:KHAN, HANIFFACILITY TYPE:
735
ADDRESS:9812 HARVEY ROADTELEPHONE:
(209) 329-5689
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:4CENSUS: 4DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Brittney ChavesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with house manager Brittney Chaves and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. All clients of this facility are nonverbal.

During a site visit on 2/13/25, LPA Moleski acquired one year’s worth of incident reports, staff schedules and time card reports, resident medication administration records (MARs), and daily care notes. These documents comprised the entirey of the year of 2022, which is the time frame provided by the complainant regarding these allegations. LPA Moleski observed an incident report which indicated a resident (R1) was given another resident's medication by mistake. According to the incident report, the facility's two-person review protocol was not followed. This medication error was addressed by Community Care Licensing Division (CCLD) staff on 6/16/22, and a citation was issued. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250205110855
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: HARVEY ESTATE
FACILITY NUMBER: 342700136
VISIT DATE: 10/28/2025
NARRATIVE
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However, LPA Moleski reviewed additional incident reports regarding medication issues which were not followed up on from that same year.

One such incident report indicated that on 3/12/22, R5 was not given their 1 p.m. dose of neuropathy medication. R5 was taken on an outing at 12 p.m., and staff on duty did not send the medication along with R5 for them to take while on the outing. According to the incident report, staff was "re-trained on the medication administration process and seriousness of missed doses." CCLD did not conduct a case management visit at the time to address this issue.

Another incident report stated that on 2/3/22, a staff member mistakenly gave R5's medication to R1. According to the incident report, the staff member misunderstood whose medication they were passing out. According to the incident report, the staff members involved were re-trained on medication procedures as a result. CCLD did not conduct a case management visit at the time to address this issue.

The department has determined the following as it relates to the allegation that staff mismanaged a resident's medication:

Based on record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 80075(b). An exit interview was held with facility administrator Hanif Khan. A copy of this report and appeal rights were left with Chaves.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250205110855
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: HARVEY ESTATE
FACILITY NUMBER: 342700136
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2025
Section Cited
CCR
80075(b)
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"(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications." This requirement was not met as evidenced by:
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Licensee has already conducted staff trainings to address the issues. No additional POC needed.
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Based on incident reports send to CCLD, clients' medications were not managed properly, which poses an immediate health, safety, and/or personal rights risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250205110855
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: HARVEY ESTATE
FACILITY NUMBER: 342700136
VISIT DATE: 10/28/2025
NARRATIVE
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LPA Moleski did not observe evidence of understaffing in the staff schedules and time card reports. LPA Moleski did not observe any evidence suggesting that staff had dropped or restrained a resident in the incident reports or daily notes collected.

No staff members interviewed were familiar with any circumstances similar to those alleged in this complaint. During LPA Moleski’s visits to this facility on 2/13/25 and 10/28/25, LPA Moleski observed clients to be clean. LPA Moleski did not observe any odors suggestive of a lack of incontinence care, and did not observe any unusual injuries suggestive of physical abuse. LPA Moleski observed an appropriate number of staff members present during these visits.

The department has determined the following as it relates to the allegations that staff restrained a resident, that staff dropped a resident, that staff left residents in soiled clothing/linens, that the facility stove was in disrepair, and that the facility was out of ratio:

Based on interviews, observation and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding the above allegations. An exit interview was held with facility administrator Hanif Khan and a copy of this report was left with Chaves.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5