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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700613
Report Date: 07/28/2026
Date Signed: 07/28/2026 05:00:18 PM

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
04/15/2026 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260415164432
FACILITY NAME:CASTLE OASIS HOME CARE LLCFACILITY NUMBER:
342700613
ADMINISTRATOR:NICHOLS, GARYFACILITY TYPE:
740
ADDRESS:5205 CASTLE STTELEPHONE:
(916) 865-7726
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
07/28/2026
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Gary Nichols, Administrator TIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Staff are forcing resident to wear diapers.
Staff yelled at resident.
Staff are not providing a comfortable environment for resident.
Staff are not responding to resident's call button in a timely manner.
Staff do not allow resident to leave her bed.
Staff made inappropriate comments towards resident.
Staff are not providing adequate food service to resident.
Staff are inappropriately isolating the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on April 15, 2026. LPA met with Gary Nichols, Administrator. Also present was staff, Tayna Safronoza. LPA observed (1) resident in the common area, (5) residents in their rooms and visitors.

During the investigation, LPA interviewed the Administrator, a caregiver, prior resident (R1), (2) family members of (R1), a nurse and a social worker who attended to (R1). LPA also interviewed (2) current residents and a family member of a current resident. Multiple pieces of documentation were reviewed. The results of the investigation are as follows:

R1 moved to the facility on March 20, 2026 and moved out April 13, 2026. The Pre-Appraisal states that R1's "overall health is okay, is recovering from a femur break, mobility is the main issue, needs glasses, hearing aids, walker assistance, is currently using a catheter but would like to work towards removing it."
The Pre-apptraisal states R1 is mentally/verbally able to follow evacuation directions but needs physical assistance with evacuating, help with bathing, dressing, moving about the facility, toileting, continence, medications and does not need night supervision/special observation due to their cognitive state.
*cont on 9099C-1..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
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 7
Control Number 59-AS-20260415164432
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: CASTLE OASIS HOME CARE LLC
FACILITY NUMBER: 342700613
VISIT DATE: 07/28/2026
NARRATIVE
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9099C-1.The Physician's Report (LIC602-dated March 16, 2026) notes R1 has a primary diagnosis of Periprostatic Fracture Around Internal Prosthetic Left Hip joint, Acute Cystitis without hematuria, skin breakdown, Hypothyroidism, Osteoarthritis and does not have any cognitive issues or exhibit behavioral expressions. Also noted is R1 has hearing/vision loss,is incontinent with bowel/bladder, has a Foley Catheter and requires assistance with repositioning/transferring, bathing, dressing/grooming, toileting, medications, is independent with feeding and can communicate and follow directions. It's also noted R1 has a history of skin breakdown.

Allegation: Staff are forcing resident to wear diapers. The allegation states the facility would not allow (R1) out of bed after 6pm to use their commode, forced (R1) to wear diapers until the morning, and (R1) would hold their urine all night.

R1 stated to LPA on 4/29/2026, confirmed they wore diapers at night and staff "didn’t change me at night." R1 added that facility staff "did not want me to use the commode at night and took it out of my room- and took my walker out too and said not to use it." R1 added, "I was stuck in bed until the next morning- It was a nice place, but no one was on duty at night".

One of R1's family members stated that R1 "had to wait until 8:00 am for help with going to the bathroom and had to hold it in", adding "R1 had a constant Urinary Tract Infection with a catheter and the nurse is aware. A second family member stated, R1 was forced to wear diapers at night and stated, "the frustrating part was the Admission Agreement stated staff would provide bathing, toileting" and other care, but it "doesn't give specific times for toileting".

The family member explained that R1 moved in with a catheter but their condition soon improved and they were moving around and ready to get the catheter removed. Also Home Health needed to monitor how R1 did without the catheter, as the catheter was causing R1 to get a Urinary Tract Infection (UTI). Staff (S2) caregiver, became upset that R1 was "calling too often" during the night for assistance with going to the bathroom once the catheter was removed and stated that both S1 and S2 told her and R1 that there is "no nighttime assistance available", and advised R1 not to push the button. This family member stated she explained to staff that R1 didn't feel comfortable going in the brief and "couldn't go in the brief".

A Home Health nurse stated she would usually visit R1 between 10 am and 3 pm and stated, it's normal for her clients to wear a brief, due to some kind of incontinence; however, the facility staff were "forcing the issue with the catheter". The nurse stated that R1 had a brief on which made them hold the urine in, contributing to a possible UTI, which was the reason the catheter was discontinued, explaining, "Yes, it was removed because R1 wanted it out- the catheter was in because of urinary retention. *cont on 9099C-2.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20260415164432
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: CASTLE OASIS HOME CARE LLC
FACILITY NUMBER: 342700613
VISIT DATE: 07/28/2026
NARRATIVE
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9099C-4. Allegation: Staff are not responding to resident's call button in a timely manner. The allegation states there is only one caregiver present, and it takes at least 20 minutes for (R1’s) requests for help to be answered.

R1 stated, "All residents were confined to their room and the doors were locked. Yes, I had to maybe wait (20) minutes". (R1’s) family member stated, confirmed that S2, does the cleaning, cooking and care giving and "doesn't bother to respond to residents- one person was not sufficient staffing". LPA and the Administrator toured the facility on July 28, 2026 and observed all (6) resident rooms to not have a locking mechanism in place. The facility does not maintain call records as they are not required to have a system that records call response times as a 6-bed facility.

Based on information obtained, the allegation is determined to be UNSUBSTANTIATED- a findings meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Allegation: Staff do not allow resident to leave her bed. The allegation states the facility would not allow (R1) to leave their bed until home health staff intervened. Additionally, staff said (R1) needed to be in wheelchair at mealtimes; they would put (R1) in the wheelchair but make them stay in their room, and then (R1) would be back in bed until the next meal.

R1 stated, "I did not ever eat at the table for meals. There were (2) men and (1) female- only those (3) sat at the table. They invited me one time, but I was not comfortable". R1 stated dinner was served at 4:30 pm and breakfast between 7-8 am, adding, "S2 is the only one who cooked". "Yes, they told me to stay in bed all day" and confirmed the Physical Therapist and others visited them during the day. The Administrator stated R1 was invited on multiple occasions to dine with the other residents in the common area, and R1 declined to eat in the common area. Additionally, the Administrator stated R1 and their visiting family member were invited to join an event at the facility, with other residents and family members, and chose to eat the food in their room instead of in the common area.

Based on information obtained, the allegation is determined to be UNSUBSTANTIATED- a findings meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.


*cont on 9099C-5..
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20260415164432
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: CASTLE OASIS HOME CARE LLC
FACILITY NUMBER: 342700613
VISIT DATE: 07/28/2026
NARRATIVE
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9099C-2.. The nurse commented "My interpretation is that the medication, Flo Max, was stopped at the facility, after R1 moved in" and explained that with urinary retention, some urine stays in, increasing the risk for a UTI. The nurse stated that the staff "didn't want to help R1 get up" and that's why they were insistent on the catheter, even after R1 was treated for a UTI.

Staff (S1) stated R1 moved out to be with family as they wanted "awake night staff", asserting that R1's family members were aware before moving in that "we have on-call NOC staff". S1 stated to R1's family member/s that the facility could hire an awake NOC staff, but it would be at the family's expense; the family declined. S1 confirmed that the facility provides incontinent care during NOC shift to "ensure there is no breakdown on the skin". S2 stated that R1 had a catheter but got a UTI, so they gave R1 an antibiotic, adding "R1's family member who is the POA. wanted someone to be with R1 as a 1:1, 24/7 in the room".

S2 explained that R1 had a catheter for one week only then used diapers, and the home health nurse knows about this. S2 stated R1 was receiving Home Health, Physical Therapy and Occupational Therapy, and "PT was having a difficult time getting R1 to stand up and exercise". S2 asserted that R1 "used diapers all of the time". S1 and S2 stated that when they attempted to transfer R1, they stated they were in pain due to their hip hurting. S1 stated that the physician wanted R1 to continue using a catheter; however, the family and R1 did not want to. S2 stated she stayed awake during the night with R1 for three nights after the catheter was removed, and R1 thought they had to urinate often, but did not when staff assisted.

Resident (R2) stated they are "independent" with toileting and there is never a situation when staff do not allow them to get out of bed after 6:00 pm, or use the commode then. A family member of resident (R3) confirmed (R3) wears Depend, and there have been "no issues".

Based on information obtained, the allegation is found to be 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 evidence to prove the alleged violation did or did not occur.

Allegation: Staff yelled at resident. The allegation states staff (S1) yelled at (R1) for wanting to use the commode rather than diaper.

R1 indicated that S1 yelled at them during the night when calling for assistance to use the commode instead of the diaper, and their family members visit during the day so did not hear it. R1’s family member corroborated this information and stated, "I did not know that they did not have awake night staff", commenting that it says on the contract they do, and stated she and another family member would rotate visitation days with R1. The Administrator stated the family knew when touring the facility there is on-call NOC staff only and not awake NOC staff.

*cont on 9099C-3..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20260415164432
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: CASTLE OASIS HOME CARE LLC
FACILITY NUMBER: 342700613
VISIT DATE: 07/28/2026
NARRATIVE
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9099C-3...A second family member stated that R1 reported to her that S1 yelled at R1, one time, about pushing the call button at night. This family member confirmed she was not there when the incident occurred. A home health nurse stated R1 told her that S1 yelled at them when they wanted to use the commode, instead of the diaper. The nurse explained that due to previous urinary retention, R1 got a UTI and when R1 didn't want to pee in the diaper, and would hold the urine in, they got another UTI.
A medical social worker and Ombudsman said it was reported to them that S1 yelled at R1.

Both S1 and S2 stated they did not ever yell at R1, or any other resident. R2 indicated they have never heard staff yell at residents, and a family member of R3, who has lived there for (3) years, stated she has never heard S1 or S2 yell.

Based on information obtained, the allegation is found to be 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 evidence to prove the alleged violation did or did not occur.

Allegation: Staff are not providing a comfortable environment for resident. The allegation states staff removed (R1’s) wheelchair and commode from the room at night.

R1 stated on April 29, 2026, that their wheelchair and commode were removed from their room at night when residing at the facility. R1 commented, "I had a wheelchair, walker and commode at both places", referring to the current care home also. LPA observed all three items to be present in their room during the interview.

Two family members, who visited R1 regularly , stated "Yes, they took away her walker, wheelchair and commode at night because they didn't want R1 to fall". A Home Health nurse stated that it was her understanding that R1’s wheelchair and commode were removed from the room at night. S2 stated they put the commode next to R1's bed and R1 would use the commode in the morning and use the bathroom also- she would have soiled Depends too." The Administrator stated the commode and wheelchair were moved closer to R1's bed to make it easier easier when getting up. The administrator also encouraged R1 to use their call button for assistance, regardless of the time of day, and tried to get resident on a regular schedule.

Based on information obtained, the allegation is found to be 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 evidence to prove the alleged violation did or did not occur.

*cont on 9099C-4...

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20260415164432
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: CASTLE OASIS HOME CARE LLC
FACILITY NUMBER: 342700613
VISIT DATE: 07/28/2026
NARRATIVE
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9099C-5.. Allegation: Staff made inappropriate comments towards resident. The allegation states staff (S1) cussed at (R1) for wanting to use the commode during the night hours, rather than using the diaper.

R1 stated S1 and S2 cussed at them in different languages, but no specific information was provided for either language. R1’s family member asserted she witnessed S2 tell R1 "You need to grow up- you're spoiled". R2, R3, and a family member of R3 indicated they have never heard staff yell or curse". Both S1 and S2 indicated they did not curses at R1. S2 stated she would never make such comments to R1, or any resident. S2 confirmed also that R1 did not speak Romanian, so would not be able to claim that staff was cussing.

Based on information obtained, the allegation is determined to be UNSUBSTANTIATED- a findings meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.



Allegation: Staff are not providing adequate food service to resident. The allegation states R1) does not feel safe to ask for needs to be met or more food and is often hungry and not fed enough.

R1 stated, "the food was alright- it was the same thing all the time- ham and cheese sandwich, mostly cold food", and they didn't feel comfortable asking for more food. One of R1's family member stated, , "Yes, R1 was hungry a lot- they served red sauce a lot and it upset their stomach, and the portions were small". The family member stated the facility also served, "ham and cheese sandwiches with soup for lunch and meat, rice with gravy for dinner- R1 was afraid to ask for more- she wasn't getting enough. R1’s second family member corroborated the information stated by the first family member.

A Home Health nurse stated "Yes, R1 was hesitant to ask for help" and R1 felt they needed to be mobile, confirming that Home Health was started on March 22, 2026. The nurse added, "I got the feeling R1 didn't feel safe due to them yelling at R1 and telling R1 to go in the diaper". R3's family member stated, “R3 has never had to ask for more food- R3 will ask for more fruit- R3 is doing amazing, receives enough food and likes their homemade soups”. LPA observed R3 to be enjoying a snack of cut up squash and popcorn in the common area on April 21, 2026.

S2 stated "R1 liked breakfast mostly- would only eat 50% of each meal". Both S1 and S2 asserted that R1 "never said they were hungry and "never asked for food". S2 commented that R1 ate every meal in their room, ate 50% and never asked for more. S2 stated R1 would eat cookies for snacks and hot chocolate every morning, and the family would bring Ensure. S2 commented "R1 always had quite a bit of food on their plate". S1 stated "Home Health never expressed any concerns about R1's physical or mental state to us- R1 was stable and Home Health reported R1 to be the same at every visit".

Based on information obtained, the allegation is determined to be UNSUBSTANTIATED- a findings meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20260415164432
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: CASTLE OASIS HOME CARE LLC
FACILITY NUMBER: 342700613
VISIT DATE: 07/28/2026
NARRATIVE
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9099C-6.. Allegation: Staff are inappropriately isolating the residents. The allegation states (R1) reported feeling isolated and only left their room for physical and occupational therapy sessions through home health.

R1 stated they did not ever eat at the table for meals and explained that there were (2) men and (1) female- only who sat at the table. R1 stated she was not comfortable eating at the table and confirmed dinner was served at 4:30 pm and breakfast between 7-8 am.

Both of R1's family member, who would regularly visit, felt R1 felt confined to their room, and that there were no other residents who had to stay in their rooms. A medical social worker stated that when she visited R1 one time at the facility, it was for (1) hour and she did not see any other residents or caregivers in the common areas.

R3's family member, who visits every afternoon, stated that R1 "was always in their room- I saw R1 sitting up one time in their bed- R1 was in an upright position. The family member commented "R1 slept a lot in their room", and some residents are kept in their room more, depending on the resident. This family member commented, "I see R4, often, and my sister and I have seen R3 too".

LPA visited on April 21, 2026 and observed (2) residents and a family member visiting in the common area for an extended period of time. LPA observed (2) residents in the common area and several visitors with other residents. LPA observed one of the visitors to comment to the Administrator that "the residents look very good, well-cared for and happy", after her visit.

Both S1 and S2 confirmed that R1 was a "one person transfer" and "R1 didn't want to come out of their room and eat meals or socialize with other residents"- R1 would have family visit for 5 hours."

Based on information obtained, the allegation is determined to be UNSUBSTANTIATED- a findings meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interview. Copy of report provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7