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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700167
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:55:44 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2023 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 25-AS-20230112144830
FACILITY NAME:ALDER GROVE SENIOR LIVING IIFACILITY NUMBER:
342700167
ADMINISTRATOR:TAN, CLIFFORDFACILITY TYPE:
740
ADDRESS:637 SHOCKLEY ROADTELEPHONE:
(650) 281-6612
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 2DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rose GomezTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
insufficient staffing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/30/2023 LPA Tryon visited the facility to complete the complaint. LPA met with Rose Gomez..
LPA has spoken with starff, witness, and residents.
Regarding the allegation of insufficient staffing, LPA learned that there are always at least 2 staff avilable in the house; sometimes more. Residents feel that their needs are met, and LPA finds no evidence that the current staff level is insufficient. Allegation is UNFOUNDED.

A finding of unfounded means that the allegation is false, could not have happened, and or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2023 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230112144830

FACILITY NAME:ALDER GROVE SENIOR LIVING IIFACILITY NUMBER:
342700167
ADMINISTRATOR:TAN, CLIFFORDFACILITY TYPE:
740
ADDRESS:637 SHOCKLEY ROADTELEPHONE:
(650) 281-6612
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 2DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rose GomezTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Restrictive visitation hours.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Regarding the allegation that there are restrictive visitation hours, through interviews with staff, review of documentation and speaking with witnesses, LPA learned that the facility does have visiting hours included in the house policies, which prospective residents and responsible parties are notified of prior to placement. It is true that many facilities have had somewhat limited visitation during the COVID pandemic. Regarding allowing families to visit when someone is on hospice, the facility appears willing to work with the families within reason to allow extended visitation hours/visits at unusual times, etc. It appears that in this case there may have been some miscommunication about visiting between staff and the family. LPA is not able to ascertain exactly what may have been said in the situation as the accounts vary somewhat. Therefore, LPA finds the allegatoin to be UNSUBSTANTIATED, A finding that the 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.
Exit interview conducted, appeal rights provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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 2