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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700525
Report Date: 04/22/2025
Date Signed: 04/22/2025 11:20:02 AM

Unsubstantiated


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
04/10/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250410161623
FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 104DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Administrator Stephen MacdonaldTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Resident sustained an injury while in care.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/22/25 to deliver complaint findings for above allegation. LPA met with administrator Stephen Macdonald and explained the purpose of the visit.

Allegation- Resident sustained an injury while in care. - Unsubstantiated
The department conducted record review, interviewed residents and staff to investigate this allegation. Record review indicated that R1 sustained a foot injury on 04/09/25 around 1pm when R1 was sitting in the common area and table lamp fell on their foot causing a cut on their foot. Staff immediately offered help to R1 and sent them to hospital to get medical care. R1 returned the same day after getting the necessary treatment. Four staff interviewed reflected that this incident was accidental, and staff offered appropriate help to R1. It has been evaluated that even though R1 got injury, but it was not due to lack and care from staff. Based on gathered information, this allegation was found to be Unsubstantiated.

A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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 4
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
04/10/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250410161623

FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 104DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Administrator Stephen MacdonaldTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring that resident is properly fed.
Staff left resident in dirty clothing for a long period of time.
Staff did not pick resident up from the hospital in a timely manner.
Staff did not clean resident's room.
Staff are over medicating a resident in care.
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/22/25 to deliver complaint findings for above allegations. LPA met with administrator Stephen Macdonald and explained the purpose of the visit.

The department conducted records review ,facility observations and interviews to investigate the complaint.



**Report continued on LIC9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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 4
Control Number 59-AS-20250410161623
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: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 04/22/2025
NARRATIVE
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***Report continued from 9099-A....

Allegation- Staff are not ensuring that resident is properly fed.-Unfounded

The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were assisting residents who require assistance with their meals and there were no issues. Residents’ interviews indicated that staff were assisting them with their dietary needs and there were no concerns. During department visit on 04/15/25, it was noted that staff were attentive to residents who require help with their meals and there were no concerns. Based on gathered information, this allegation was found to be Unfounded.

Allegation- Staff left resident in dirty clothing for a long period of time.-Unfounded

The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were changing residents’ clothes daily and as needed, not leaving residents in dirty clothes and there were no issues to address. Residents’ interviews indicated that staff were assisting them with their care needs and there were no concerns. During department visit on 04/15/25, it was noted that residents were well groomed and in good care and there were no concerns. Based on gathered information, this allegation was found to be Unfounded.

Allegation- Staff did not pick resident up from the hospital in a timely manner. - Unfounded

The department conducted interviews with four staff to investigate this allegation. Staff interviews reflected that facility was not arranging any transportation services for any residents once they were ready to return to facility after ER or hospital visit, and it is arranged by ER/Hospital staff. Record review for resident R1 did not indicate any incident, where staff did not pick R1 from hospital in timely manner. Based on this information, this allegation was found to be Unfounded.

Allegation- Staff did not clean resident's room. -Unfounded

The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were providing laundry and housekeeping service as agreed in residents’ admission agreements and there were no issues to address. Residents’ interviews indicated that staff were assisting them with laundry and housekeeping tasks in timely manner and there were no concerns. During department visit on 04/15/25, it was noted that facility was clean and odor free and there were no concerns. Based on gathered information, this allegation was found to be Unfounded.

***report continued......

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250410161623
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: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 04/22/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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24
25
26
27
28
29
30
31
32
***Report continued from 9099-A....

Allegation- Staff are over medicating a resident in care. -Unfounded

The department conducted record review, interviewed residents and staff to investigate this allegation. Four residents’ interviews indicated that staff were giving them medications per their physician’s orders. Four staff interviews reflected that staff were following resident’s physician’s orders and not mismanaging residents’ medications. Record review for R1s medications indicated that staff were administering R1s medications per their physician’s orders and there were no issues identified. Based on gathered information, this allegation was found to be Unfounded.

Allegation- Staff did not safeguard resident's personal belongings. -Unfounded

The department conducted interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were safeguarding residents’ belongings per facility protocol and there were no issues to address. Residents’ interviews indicated that staff were safeguarding their personal items, assisting them to locate any missing items as needed, and there were no concerns. During department visit on 04/15/25, it was noted all personal belongings for R1 was labeled and secured in R1s room. Based on gathered information, this allegation was found to be Unfounded.


A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. A copy of this report has been provided to facility.


SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4