342700506-4-29-2026-59-AS-TORZ-DTUTMY-20260507145153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700506
Report Date: 04/29/2026
Date Signed: 04/29/2026 05:32:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
03/13/2026 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20260313115040

FACILITY NAME:	KENTFIELD ESTATES RANCH RCFE		FACILITY NUMBER:	342700506
ADMINISTRATOR:	SOUMAHORO, MARIAM GBATY		FACILITY TYPE:	740
ADDRESS:	3800 SILVER SPUR WAY		TELEPHONE:	(916) 904-0027
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Caregivers		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff did not administer medications as prescribed.

INVESTIGATION FINDINGS:

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On 4/29/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with caregiver S1 to deliver complaint findings for the above allegation. LPA spoke with Admin by phone but Admin was not available to attend.

LPA reviewed resident records, facility and conducted interviews.
LPA finds that the allegations cited above are substantiated.

Based on medication records review Nov 2024- Dec 2025, and staff interviews it was found that there were many irregularities in medication administration records (MARs) and medications ordered as as needed were administred daily without required PRN record of medication, reason needed and result of the medication. There were also gaps in medication when refills were late. Statements indicated that refills were ordered but family delivery was not always reliable. The system were changed to pharmacy delivery.

report continued...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

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 5

Control Number 59-AS-20260313115040

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KENTFIELD ESTATES RANCH RCFE	FACILITY NUMBER: 342700506
	VISIT DATE: 04/29/2026

NARRATIVE

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As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with designee . Copy of this report and appeal rights provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 59-AS-20260313115040

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KENTFIELD ESTATES RANCH RCFE	FACILITY NUMBER: 342700506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/27/2026 Section Cited CCR 87465	1 2 3 4 5 6 7	Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on records and interview statements. This posed a potential risk to the resident.	1 2 3 4 5 6 7	Licensee will submit a statement of procedures for med intakes, physicians orders on file, documentation of PRNs administered and notification to MD or missed or refused medications. This procedure will be reviewed with all staff and verified by signatures by the POC date of 5/27/26
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
03/13/2026 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20260313115040

FACILITY NAME:	KENTFIELD ESTATES RANCH RCFE		FACILITY NUMBER:	342700506
ADMINISTRATOR:	SOUMAHORO, MARIAM GBATY		FACILITY TYPE:	740
ADDRESS:	3800 SILVER SPUR WAY		TELEPHONE:	(916) 904-0027
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Caregivers		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff lack of care and supervision lead to resident need for emergency medical care.

INVESTIGATION FINDINGS:

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On 4/29/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with caregiver/ designee.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

Records reviews and interviews found R1 to have care needs related to cognitive and physical disability. Staff interviewed knowledge and understanding of care needs and that care was provided as needed.
On 11/10/25, R1 was hospitalized when staff observed a change of condition. In hospital, R1 was found to have pneumonia, sepsis, high blood saline and high glucose. Staff called 911 when change was apparent.
R1 was on a low salt diet and hydration was maintained. It is unclear if the high saline was the result of the pneumonia effect on metabolism. Though R1 was identified as diabetic, records had previously not noted diabetes risk or a diabetic diet until after 11/10/25.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 59-AS-20260313115040

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KENTFIELD ESTATES RANCH RCFE	FACILITY NUMBER: 342700506
	VISIT DATE: 04/29/2026

NARRATIVE

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Therefore, there was not sufficient evidence to conclude that a lack of care and supervision lead to the hospitalization.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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 with designee..

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC9099 (FAS) - (06/04)

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