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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700185
Report Date: 03/27/2026
Date Signed: 03/27/2026 05:50:35 PM

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
01/29/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260129115313
FACILITY NAME:CUPINO HOMEFACILITY NUMBER:
342700185
ADMINISTRATOR:MONICA BUTAYFACILITY TYPE:
735
ADDRESS:8636 LILYPAD LANETELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 4DATE:
03/27/2026
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Monica Butay and Raul CupinoTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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staff physcially abused resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Wolf Petersen, arrived unannounced at 4:00pm with an Alta Regional Service Cooridnator, ARSC, Mai Thor to conduct a complaint investigation into the above allegation. The LPA met with administrator Monica Butay and Licensee Raul Cupino to explain the purpose of the visit.

LPA interviewed 2 staff, while ARSC interviewed 4 residents. R1 made a statement that S1 physically abused her by dragging her by her hair, it was learned in interview that R3 provided a similar statement about a seperate incident where S1 was grapping R3's hair and chin. S4 provided a statement that S1 threatened to damage her property but neither made a threat against her person or carried out any property damage. Staff/Licensee of the facility provided a statement that they did not find it likely that S1 physically abused a resident, and S1 had decided to quit the facility. S1 denies the allegation.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D. A copy of the report was read and given to the administrator, appeal rights provided. exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
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-20260129115313
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: CUPINO HOME
FACILITY NUMBER: 342700185
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2026
Section Cited
CCR
80072(a)(3)
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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: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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 No immediate POC. LPA Propses not putting Ray on the schedule for tomorrow which is reported to be his last day, and then having staff take a training reviewing the personal rights of the clients for title 22. a roster of attending staff should be sent to the LPA by 4/3/26.
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This requirement was not met as evidenced by: a consensus of statements that a staff of the facility was inflicting pain and or threating the residents as a punishent.
This poses a risk to the clients health, saftey, and personal rights.
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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: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2