342700722-11-17-2025-27-AS-SRIN-DP82HS-20251209162512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700722
Report Date: 11/17/2025
Date Signed: 11/17/2025 01:56:52 PM

Unsubstantiated

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
05/20/2025 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20250520104756

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: 109	DATE:	11/17/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Elena Cuevas		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff did not ensure that residents were hydrated.
Staff did not ensure that residents' incontinence needs were met.
Staff did not assist residents with bathing.

INVESTIGATION FINDINGS:

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On 11/17/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a follow-up complaint visit the allegations noted above.
LPA met with Executive Director/Administrator, Elena Cuevas (AD), and stated the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations.

Allegation – staff did not ensure that residents were hydrated:
The investigation into this allegation consisted of interviews with staff and residents, reviews of relevant records and facility observation. Additionally, statements and interviews from residents’ family members were reviewed.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

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 3

Control Number 27-AS-20250520104756

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: 11/17/2025

NARRATIVE

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Allegation – staff did not ensure that residents were hydrated (con't):
Through interviews with residents, they stated that they had access to water and fluids whenever they needed them. They described hydration stations placed throughout the facility, including in common areas like the movie theater and the café on the second floor. They also stated that staff were available to help if needed. Interview with a family member during a visit on 7/28/25, who visited their parent regularly, stated that they have never seen any issues with hydration. Interview with some staff acknowledged that the facility was experiencing staffing challenges, especially in the Memory Care (MC) Unit, but did not report any issues related to hydration.
A report from an Ombudsman which they noted that one hydration was observed in the MC Unit but was missing cups and had damage to its surface. During a site visit by LPA Arielle Pascua and LPA Villanueva on 7/28/25, hydration stations were observed in both the Assisted Living (AL) Unit and MC Unit. LPAs observed water and other fluids being served to residents during lunch, and hydration stations appeared stocked and accessible during this visit.
Based on interviews, record reviews, and observation, there is not enough evidence gathered to support this allegation. Therefore, the allegation was UNSUBSTANTIATED.

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Allegation – staff did not meet resident’s incontinence needs:
The investigation into this allegation consisted of interviews with staff and residents, reviews of relevant records and site visit to observe care practices. Additionally, statements and interviews from residents’ family members were reviewed.
Residents interviewed reported that staff responded quickly to call buttons and helped them with toileting and bathing when needed. None of the residents that were interviewed expressed concerns about being left in soiled clothing or not receiving help. One family member of a resident stated that they had no complaints and believed the facility as well-staffed and attentive to residents’ needs. Statement from another family member expressed contradiction and reported that their parent was not changed between 8am and 1:30pm on 5/21/25. They also claimed that routine incontinent brief changes were missed due to staffing shortages in the MC Unit.
Staff interviews revealed staffing was inconsistent, especially in the mornings, and that staffing agency workers were being used to fill gaps. Memory Care Director also confirmed providing direct care to residents due to staff shortages.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20250520104756

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: 11/17/2025

NARRATIVE

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Allegation – staff did not meet resident’s incontinence needs (con't):
During LPAs Pascua and Villanueva’s site visit on 7/28/25, staff were observed assisting residents during lunch, and no signs of neglect or hygiene issues were noted at this visit. LPAs also observed outside agency staff were working during this shift. While staffing issues were evident, there is not enough consistent evidence to prove that residents’ incontinent needs were being neglected. Therefore, the allegation is UNSUBSTANTIATED.

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Allegation – staff did not assist residents with bathing:
The investigation into this allegation included interviews with sample residents, staff, and family members, reviews of reports, and site visit to observe care practices.
The residents that were interviewed stated that they receive help with bathing when they asked for it. One resident mentions that they are mostly independent, but staff are available when assistance is requested. Another resident confirmed that staff usually help with bathing and toileting. None of the residents interviewed reported being denied help or left unattended. During a site visit on 7/28/25, a family member, who was visiting a resident, stated that they had no concerns and believed the facility was meeting their parent’s needs. A statement from another family member did not mention bathing from their statement but did express concerns about staffing shortages and general neglect in the MC Unit.
Staff interviews and based on Ombudsman's reports confirmed that facility was experiencing staff issues. Memory Care Director have reported that they sometimes help with resident care.
During LPAs Pascua and Villanueva's site visit on 7/28/25, they observed both AL and MC units. No signs of poor hygiene or missed bathing care were noted during this visit. LPAs also observed outside agency staff were working during this shift. Although staffing issues were reported, there is insufficient evidence to show that staff did not assist residents with bathing. Therefore, the allegation is UNSUBSTANTIATED.
Note that unsubstantiated findings mean that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

No citations are being issued at this time. An exit interview was conducted with AD and a copy of this report and appeal rights were provided upon exit.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC9099 (FAS) - (06/04)

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