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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700805
Report Date: 01/22/2026
Date Signed: 01/26/2026 09:52:44 AM

Substantiated


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
12/08/2025 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20251208154031
FACILITY NAME:NORTHERNCARE FACILITYFACILITY NUMBER:
342700805
ADMINISTRATOR:WOODWARD, ROSE BALUROFACILITY TYPE:
740
ADDRESS:5016 WATERBURY WAYTELEPHONE:
(530) 762-8199
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
01/22/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rose WoodwardTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not properly trained
Staff are not meeting the needs of the residents
Staff do not practice effective infection control for scabies
Staff mishandled a resident's personal belongings
INVESTIGATION FINDINGS:
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On (date), Licensing Program Analyst (LPA) Kevin Mknelly spoke to xxx xxx, title... to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

Statements and video found that on 5/28/25, S1 and S2 were employed at this home. A department review of criminal background checks and transfer was not completed for S1 and S2. Administrator stated S1 and S2 arrived at the home on the evening of 5/27/25. Administrator stated that they did training of these new staff yet no training records are on file. On 5/28/25, S1 is recorded in a family/ resident video as providing an unsafe transfer and to be handled in an undignified manor- pushed and pulled while in bed, pillows dropped on resident, no discussion to resident about the assistance being provided.
Report continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
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 4
Control Number 59-AS-20251208154031
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: NORTHERNCARE FACILITY
FACILITY NUMBER: 342700805
VISIT DATE: 01/22/2026
NARRATIVE
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S1 attempted a one-person transfer for R1, who is a 2-person transfer. Administrator stated they had left S1 and S2 alone with residents on 5/28/25. S1 and S2 had employment terminated.
The allegation regarding ineffective infection control was also made in and substantiated for complaint 59-AS-20251119202205. Therefore, though substantiated here, citation was issued for that complaint only.
Administrator stated that R1’s personal laundry and linens were not kept separate from other residents. R1’s linens would be, at times, be returned to the house’s linen supplies and used on other resident beds. Administrator also acknowleged that their dryer stopped working, clothes were hung to dry outside and the current dryer does not get sufficiently hot. During a contact precautions infection in the home, these instances constitute mishandling of resident belongings.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20251208154031
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: NORTHERNCARE FACILITY
FACILITY NUMBER: 342700805
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2026
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee will submit a statement of
training, oversite and supervisory actions by the POC date of 1/13/26.
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This requirement was not met based on video and statements that found S1 did not provide appropriate transfer request to R1. This posed and immediate risk to R1.
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Type B
02/06/2026
Section Cited
CCR
87411(c)
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Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training… This requirement was not met based on records review and interview finding no recorded training for S1 or S2. This posed a potential risk to residents.
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Licensee will submit a statement of understanding as well as a facility training record template used to meet this requirement by the POC date of 2/6/26.
Type B
02/06/2026
Section Cited
CCR
87307(a)(3)(4)
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 87307 Personal Accommodations and Services (a)(3)(F) Basic laundry service… This requirement was not met based on statements that resident personal belongings were not kept separate from others and that R1’s personal linens were not properly laundered. This posed a potential risk to resident.
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Licensee will submit proof of staff training regarding proper laundering of resident belongings, control of infection and ensuring resident's personal belongings by the POC date of 2/6/26.
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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
12/08/2025 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20251208154031

FACILITY NAME:NORTHERNCARE FACILITYFACILITY NUMBER:
342700805
ADMINISTRATOR:WOODWARD, ROSE BALUROFACILITY TYPE:
740
ADDRESS:5016 WATERBURY WAYTELEPHONE:
(530) 762-8199
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: DATE:
01/22/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not keep the facility free from pests.
INVESTIGATION FINDINGS:
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 On 1/22/26, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with administrator.
LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.
Administrator acknowledged that there was a time of a insect infestation at the home. From evidence gathered it was unclear whether or not the problem was remedied timely, by pest control or purchase by the licensee, and effectively, At the time of this investigation, insects were not observed by LPA.
The Administrator acknowledge in interviews that Administrator and other live-in family members have had loud verbal arguments in the presence of residents witch contributed to resident discomfort. Through discussions with LPA and Ombudsman, the behavior has been corrected and was not observed during the course of this investigation.
As a result of this investigation, LPA finds allegation to be (US)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 the evidence to prove that the alleged violation occurred.
Exit interview with administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4