342700722-10-23-2025-27-AS-SRIN-DMRQ2J-20251024114712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700722
Report Date: 10/23/2025
Date Signed: 10/23/2025 09:41:22 AM

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
09/12/2025 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250912172728

FACILITY NAME:	WELLQUEST OF ELK GROVE		FACILITY NUMBER:	342700722
ADMINISTRATOR:	ELENA CUEVAS		FACILITY TYPE:	740
ADDRESS:	8871 E STOCKTON BLVD		TELEPHONE:	(916) 689-1000
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	170	CENSUS: 112	DATE:	10/23/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elena Cuevas		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Unsafe furniture in the Memory Care patio area

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Elena Cuevas and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski toured the memory care portion of this facility on 9/18/25 and inspected the patio furniture. LPA Moleski noticed that the furniture currently in use had been changed since the time of his last tour of memory care patio areas on 5/29/25. LPA Moleski was told by staff that the blue-and-black metal-framed furniture was removed around the end of August.

LPA Moleski reviewed two incident reports from this facility. The first described a resident (R1) suffering a fall on July 8, 2025. According to the report, R1 fell in the memory care patio area while trying to stand up from a chair. A second report described another resident (R2) falling while trying to stand up from a chair on September 4, 2025. [continued on 9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250912172728

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: WELLQUEST OF ELK GROVE	FACILITY NUMBER: 342700722
	VISIT DATE: 10/23/2025

NARRATIVE

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LPA Moleski interviewed Cuevas, nine staff members of this facility, and three non-staff witnesses, comprised of one resident’s family member, another resident’s friend, and an ombudsperson.

In interviews, multiple staff members said that the blue-and-black chairs were lightweight, flimsy, and posed a hazard to residents in care. In an interview, Cuevas described the chairs as “lightweight,” and said that some residents were pushing the chairs back when they stood up.

S1 said the chairs were replaced due to falls and due to questions of sturdiness. S1 said the chairs had a tendency to “go back,” and residents needed something sturdy. S1 said that R1 plops down heavily when they sit, and they also rock when standing up. S1 said they had observed the chairs moving around when residents rocked in them. S1 said they had concerns about the safety of the chairs. S2 said the chairs had a tendency to rock, and described them as “a bit shaky” and not “that sturdy.” S3 said the chairs were wobbly. “Anything that’s wobbly is going to be unsafe for a senior,” S3 said. S5 said that the chairs might have been unsafe. S5 said the chairs were thin, and residents tend to slam down when they sit. S5 said they had observed the chairs tipping back when residents sat down. S7 said there may have been a fall risk posed by the chairs. S7 said the chairs were very light and thin, which meant residents sitting down heavily might tip their chairs back. S7 said that R2 did have a habit of sitting down hard.

S3, S4, S5, and S7 said they responded to R1’s fall as described above. S3, S4, S5 said R1 was either trying to stand up from a chair or sit down into one, although they did not witness the fall. S7 said that when they responded, they observed R1 lying back up against a window pane. S7 said it appeared that R1 had fallen backward out of the chair.

S2 said they responded to R2’s fall as described above. S2 said that, upon arrival, they observed R2 on the floor propping themselves up. S2 said it appeared that R2’s chair had tipped backward.

In interviews, multiple staff members were aware that loose screws had been falling out of the chairs (S1, S2, S3, S4). According to S1, screws started coming out of the chairs about a month after the chairs were first put out. In a previous interview, S1 told LPA Moleski the chairs were put out around the middle of May. In a previous interview, S1 told LPA Arielle Pascua that screws were coming out of the chairs daily. S1 told LPA Moleski that maintenance staff were re-tightening the screws. [continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250912172728

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: WELLQUEST OF ELK GROVE	FACILITY NUMBER: 342700722
	VISIT DATE: 10/23/2025

NARRATIVE

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S2 said that any chairs that were losing screws were removed when they were noticed. S4 said that maintenance staff were reinforcing the chairs with loose screws.

In interviews, visitors of this facility voiced concerns over the patio chairs. A resident’s family member said they had observed wobbly chairs and chairs with missing screws, which they removed from the area. A different resident’s friend had observed screws coming loose from chairs, which maintenance staff screwed back into the chairs. On one occasion, chairs with loose screws were removed from the area when brought to the attention of staff, according to the resident's friend. The resident’s friend had also observed the chairs wobbling and/or tipping when residents sat down heavily into them.

Based on the above, facility staff were aware of issues with the blue-and-black model of chair which were used in the memory care patio area between approximately mid-May and late August 2025. These issues included a tendency for the chairs to tip and/or wobble when residents sat down into them and a tendency for the chairs to lose screws. Although some staff reported that chairs with loose screws were reinforced by maintenance or removed from the patio area, at least two visitors independently discovered screws coming loose from chairs. Despite these known issues, the blue-and-black chairs remained available to residents for more than three months.

The department has determined the following as it relates to the allegation that unsafe furniture was present in the memory care patio area:

Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 87303(a). An exit interview was held with Cuevas. Appeal rights and a copy of this report were left with Cuevas.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20250912172728

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: WELLQUEST OF ELK GROVE	FACILITY NUMBER: 342700722
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 10/24/2025 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	“The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.” This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee has already removed the chairs described in this report. No further POC necessary at this time.
	8 9 10 11 12 13 14	Based on interviews and record review, the facility’s memory care patio area was not maintained in a safe manner at all times, which poses/posed a potential health, safety, and/or personal rights risk.	8 9 10 11 12 13 14
	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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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