342700722-12-31-2025-27-AS-SRIN-DQM22G-20260123160043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700722
Report Date: 12/31/2025
Date Signed: 12/31/2025 03:28:31 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
06/24/2025 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20250624085139

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:	12/31/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Elena Cuevas		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not assist resident with care needs in a timely manner.
Staff did not ensure adequate personal care supplies were available for resident.
Staff did not ensure resident's dietary needs were met.
Staff did not adequately address a change in resident’s condition.
Staff did not prevent residents from disturbing other residents.

INVESTIGATION FINDINGS:

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On 12/31/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a follow up complaint investigation visit regarding the allegations noted above. LPA met with the Executive Director/Administrator, Elena Cuavas (AD), and stated the purpose of the visit.
This investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted facility observations during multiple visits, interviewed on‑duty staff and residents, and reviewed all relevant documents related to R1.

Allegation 1- Staff did not assist residents with their care needs in a timely manner:
The investigation included interviews with staff, residents, and a visiting family member, a review of records, and observations made on 7/2/25, 7/18/25, and 12/29/25. During staff interviews, staff explained that residents in the Memory Care (MC) unit are checked about every two hours, or more often if needed. Staff said they usually care for about 6–8 residents each shift. Staff also explained that between March and July 2024, the facility had consistent staffing with caregivers, med techs, a dining room server, a program assistant, and a Memory Care Director on duty. Staff reported no staffing shortages or call-offs during this time. Staff shared that they did not remember every detail about Resident 1 (R1) because the events happened more than a year ago.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

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 7

Control Number 27-AS-20250624085139

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: 12/31/2025

NARRATIVE

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They explained that R1 first lived in Assisted Living (AL) and later moved to Memory Care as health and behavior changed. Staff said R1 sometimes refused care and liked things done a certain way, which made helping R1 more difficult. Staff also said R1 sometimes tried to stand up on their own even though R1 was no longer able to walk safely. At night, R1 sometimes refused to get out of bed to use the bathroom, so staff cleaned R1 in bed. Staff also said R1 had a long history of UTIs, even when R1 lived in AL and was more independent. Staff confirmed that R1 was not assessed to have one-on-one care but did receive help during meals because R1 ate slowly.
Staff said they checked on residents often and followed care plans for bathing, dressing, toileting, and other ADLs. Residents with mobility problems were kept in common areas where staff could watch them more easily.
Record reviews showed that after R1 broke their collarbone, staff followed the doctor’s orders and helped R1 with all ADLs while keeping R1’s arm in a sling. R1’s care plan was updated eight times between July 2021 and February 2024 due to falls, UTIs, and changes in condition. Progress notes from 7/2/21 to 7/25/24 showed entries where R1 refused care and entries showing staff checked on R1 often and responded to their needs. Service plans from 2021–2024 showed that R1 went from being mostly independent to needing much more help by late 2023. Physician’s Reports from 2021 and 2024 also showed a clear decline in mobility, diet needs, continence, and cognitive abilities. There was no indication that R1 needed one-on-one care. Records also showed that staff received training in several areas, including fall incidents, memory care rounds, reporting procedures, hydration, proper storage of personal items in memory care, environmental safety, dementia care, hygiene, wellness checks, and daily care routines .Residents interviewed during the investigation said staff helped them with bathing, hygiene, and other needs. They did not report problems with call-button response times. A family member visiting the MC unit also said they had no concerns about staffing, care, or food. During LPA observations on 7/2/25, 7/18/25, and 12/29/25, staff were seen helping residents with meals and feeding those who needed assistance.
Based on interviews, record reviews, and observations, there was not enough evidence to show that staff did not assist residents with their care needs in a timely manner. Although R1 sometimes refused care and R1’s condition declined over time, the information gathered shows that staff followed the care plan and responded to her needs. Therefore, this allegation is unsubstantiated.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 27-AS-20250624085139

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: 12/31/2025

NARRATIVE

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Allegation 2- Staff did not ensure adequate personal care supplies were available for the resident: The investigation included staff interviews, resident interviews, record reviews, and observations made on 7/2/25, 7/18/25, and 12/29/25.
During staff interviews, staff explained that residents’ families usually bring personal care supplies such as wipes, briefs, and hygiene items. Staff stated that if a resident is running low on supplies, they call the family to let them know more supplies are needed. Staff also said the facility keeps basic supplies on hand and can provide them if a resident temporarily runs out. Staff reported they had not seen or heard of residents’ belongings being taken or stolen from their rooms. Regarding Resident 1 (R1), staff said R1’s family regularly brought supplies and that R1 often had more than enough. Staff did not recall any time when R1 ran out of supplies but noted that R1 moved out a long time ago, making details harder to remember. Residents that were interviewed during the investigation did not report any problems with running out of supplies. They also did not report any concerns about other residents or staff taking their belongings.
Record reviews showed that R1’s progress notes from 7/2/21 to 7/25/24 contained many entries about R1 refusing care and entries showing staff checked on R1 periodically. The notes also showed staff responded to R1’s medical needs. Review of R1’s service plans from 2021, 2022, and 2023 showed that R1’s care needs increased over time as R1’s condition declined. The plans did not show any concerns about lack of supplies. Review of R1’s Physician’s Reports from 2021 and 2024 also showed a decline in health and functioning but did not indicate any issues with missing or inadequate personal care supplies. Records also showed that staff received training in several areas, including fall incidents, memory care rounds, reporting procedures, hydration, proper storage of personal items in memory care, environmental safety, dementia care, hygiene, wellness checks, and daily care routines. During LPA observations on 7/2/25, 7/18/25, and 12/29/25, staff were seen assisting residents with meals and helping those who needed feeding support. No concerns related to supplies were observed.
Based on interviews, record reviews, and observations, there is not enough evidence to show that the facility did not to provide adequate personal care supplies for R1. Staff reported that supplies were available, families were notified when more were needed, and residents confirmed they did not experience shortages. Therefore, this allegation is unsubstantiated.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 27-AS-20250624085139

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: 12/31/2025

NARRATIVE

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Allegation 3- Staff did not ensure the resident’s dietary needs were met: The investigation included interviews with staff, residents, and a visiting family member, as well as a review of records and observations made on 7/2/25, 7/18/25, and 12/29/25.
During staff interviews, staff shared that Resident 1 (R1) first lived in the Assisted Living (AL) area and was mostly independent at that time. Staff said R1 liked things done a certain way and had a small appetite. They described R1 as “petite” and a “picky eater,” and said they encouraged R1 to eat more when needed. Staff also remembered that R1 sometimes received Ensure supplements and vitamins to help with weight management. When R1 later moved to the Memory Care (MC) unit, staff said R1’s condition was declining, but they did not recall any concerns about R1’s dietary needs not being met.
Residents that were interviewed during the investigation did not report any problems with their own dietary needs. Several residents said they liked the food served at the facility and that alternative menu options were available if they did not want what was offered. A family member visiting their loved one in the MC unit also reported no concerns about food, care, or staffing.
Record reviews did not show any evidence that R1’s dietary needs were unmet. Service plans from 2021 through 2023 consistently listed R1 as being on a regular diet with no special dietary restrictions. There were no notes about weight loss concerns, nutritional problems, or unmet dietary needs. The service plans mainly showed changes in R1’s cognitive abilities and care needs over time, not changes in diet. Progress notes from 7/2/21 to 7/25/24 showed entries about R1 refusing care and entries showing staff checked on R1 often and responded to R1’s needs. Review of R1’s Physician’s Reports from 2021 and 2024 showed a clear decline in health and functioning, but there was no indication that dietary needs were ignored or not provided. Records also showed that staff received training in several areas, including fall incidents, memory care rounds, reporting procedures, hydration, proper storage of personal items in memory care, environmental safety, dementia care, hygiene, wellness checks, and daily care routines. During LPA observations on 7/2/25, 7/18/25, and 12/29/25, staff were seen helping residents with meals and feeding those who needed assistance in the dining/activity area.
Based on interviews, record reviews, and observations, there is not enough evidence to show that the facility did not to meet R1’s dietary needs. Staff reported encouraging R1 to eat, residents reported no issues with food service, and records showed no dietary concerns. Therefore, this allegation is unsubstantiated.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 27-AS-20250624085139

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: 12/31/2025

NARRATIVE

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Allegation 4- Staff did not adequately address a change in the resident’s condition:
The investigation included staff interviews, record reviews, and observations. During staff interviews, staff explained that Resident 1 (R1) first lived in the Assisted Living (AL) area and needed very little help at that time. Staff said R1 was mostly independent and liked things done a certain way. When R1 later moved to the Memory Care (MC) unit, staff noticed R1’s condition was declining. Staff described R1 as a “petite” person and said R1’s needs increased over time. Staff said they checked on residents often, followed care plans, and kept residents with mobility problems in common areas where staff could watch them more closely. Regarding R1’s change in condition, staff stated that after R1 fractured collarbone, they followed the doctor’s orders. Staff were told to help R1 with all activities of daily living (ADLs) while keeping arm in a sling. According to staff, R1’s care plan was updated eight times between July 2021 and February 2024 to reflect changes related to falls, UTIs, and overall decline. Staff said these updates were shared during shift changes so all caregivers knew how to support R1. Staff also said the facility notified R1’s responsible party when supplies were running low and documented communication through emails, care conferences, and progress notes.
In response to R1’s falls on June 3, June 12, and July 16, 2024, the Memory Care Director, Executive Director, Regional Care Director, and VP of Health Services reviewed R1’s care plan and made adjustments. Incident reports were completed, and a change-in-condition assessment had already been done on February 1, 2024. Staff notified R1’s doctor and POA after each fall. Staff were also told to check on R1 more often and keep R1 in common areas for closer supervision. EmpowerMe, the onsite physical therapy provider, was contacted, but they could not treat R1 due to R1’s insurance.
The facility also addressed resident-to-resident issues. Staff reported that some residents wandered into other rooms. One resident, a retired security guard, liked to check doors. Staff were instructed to lock doors after leaving residents’ rooms. Staff also received training on redirecting wandering residents. The facility confirmed that R1’s door was locked when needed.
Record reviews showed that R1’s progress notes from 7/2/21 to 7/25/24 included entries about R1 refusing care and entries showing staff checked on R1 regularly. The notes also showed staff responded to R1’s medical needs. Review of R1’s service plans from 2021 to 2023 showed a clear decline in condition over time.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 27-AS-20250624085139

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: 12/31/2025

NARRATIVE

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R1 went from being mostly independent in 2021 to needing much more help by late 2023. Review of R1’s Physician’s Reports from 2021 and 2024 also showed a major decline in mobility, cognition, and physical health. There was no indication that R1 required one-on-one care.
Records also showed that staff received training in several areas, including fall incidents, memory care rounds, reporting procedures, hydration, proper storage of personal items in memory care, environmental safety, dementia care, hygiene, wellness checks, and daily care routines.
Based on interviews, record reviews, and observations, there is not enough evidence to show that staff did not address changes in R1’s condition. The facility updated care plan multiple times, notified medical providers and family, completed incident reports, and increased supervision when needed. Therefore, this allegation is unsubstantiated.

***********************************************************************

Allegation 5- Staff did not prevent residents from disturbing other residents:
The investigation included staff interviews, record reviews, and observations conducted on 7/2/25, 7/18/25, and 12/29/25. During staff interviews, staff explained that Resident 1 (R1) first lived in the Assisted Living (AL) area and needed very little help at that time. Staff said R1 was mostly independent and liked things done a certain way. When R1 later moved to the Memory Care (MC) unit, staff noticed her condition was declining. Staff described R1 as a “petite” person and said R1’s needs increased over time. Staff also explained that between March and July 2024, the facility had consistent staffing with caregivers, med techs, a dining room server, a program assistant, and a Memory Care Director on duty. Staff reported no staffing shortages or call-offs during this time. Staff said they checked on residents often, followed care plans, and kept residents with mobility problems in common areas where staff could watch them more closely.
Regarding resident-to-resident interference, staff acknowledged that some residents in the MC unit wandered into other residents’ rooms. Staff described one resident, a retired security guard, who liked to check doors because of past habits. Staff said they were instructed to lock residents’ doors after leaving their rooms and to lock all doors daily to reduce wandering. Staff also reported receiving training on redirecting residents who wandered or entered other rooms. Staff confirmed that R1’s door was locked when appropriate to prevent unwanted entry.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 27-AS-20250624085139

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: 12/31/2025

NARRATIVE

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Record reviews showed that R1’s progress notes from 7/2/21 to 7/25/24 included entries about R1 refusing care and entries showing staff checked on R1. The notes also showed staff responded to R1’s medical needs. Review of R1’s service plans from 2021 to 2023 showed a clear decline in condition over time, but there were no notes indicating that other residents disturbed or that staff failed to intervene. Review of R1’s Physician’s Reports from 2021 and 2024 also showed a major decline in mobility, cognition, and physical health, but again, no documentation of resident-to-resident disturbances affecting care. Records also showed that staff received training in several areas, including fall incidents, memory care rounds, reporting procedures, hydration, proper storage of personal items in memory care, environmental safety, dementia care, hygiene, wellness checks, and daily care routines.
During LPA observations on 7/2/25, 7/18/25, and 12/29/25, staff were seen assisting residents with meals and providing supervision in common areas. LPA did not observe any residents disturbing others during these visits. LPA observed cameras in the MC hallways and fall detection devices in some MC residents’ rooms.
Based on interviews, record reviews, and observations, there is not enough evidence to show that the facility did not prevent residents from disturbing other residents. Staff reported taking steps to redirect wandering residents, locking doors when needed, and supervising residents in common areas. Cameras in the hallways and fall detection devices installed in residents’ room provided additional type of supervision. Therefore, this allegation is unsubstantiated.

A finding of unsubstantiated means that although the allegation may be valid or may have happened, the preponderance of evidence is not met.

No deficiencies were cited as a result of this visit. An exit interview was conducted, and a copy of this report and appeal rights were provided.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC9099 (FAS) - (06/04)

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