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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700872
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:23:45 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230906100708

FACILITY NAME:MASON'S HOME, LLCFACILITY NUMBER:
342700872
ADMINISTRATOR:WONG, SALLYFACILITY TYPE:
735
ADDRESS:4521 EXCELSIOR RDTELEPHONE:
(916) 402-3830
CITY:MATHERSTATE: CAZIP CODE:
95655
CAPACITY:4CENSUS: 4DATE:
09/06/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Personal Rights:
1) Administrator denies activities to resident with other residents when going out on community activities.
2) Resident is served smaller portions of food than the other residents.
3) Staff is swearing at resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Mason's Home LLC on 9/6/23 at 2:00pm to inform the licensee of complaint allegations mentioned above.

During this investigation LPA Gould interviewed three staff members and two residents (See confidential name list LIC-811 dated 9/6/23). Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. All staff members denied excluding resident from planned activities. R1 provided several examples of activities she has attended such as going to Wal-Mart and Marshall's for shopping, going to a farm and to the lake. LPA confirmed R1 is at day program 5 days a week and residents who cannot participate in day program participate in other outings with staff. R1 alleges that she is served smaller portions of food. All staff interviewed deny the allegation. R1 showed LPA a picture of food but LPA could not determine if the food was prepared at the facility or if it was even R1's meal. LPA had no reference to compare with servings to other residents.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230906100708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MASON'S HOME, LLC
FACILITY NUMBER: 342700872
VISIT DATE: 09/06/2023
NARRATIVE
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Regarding allegations of staff swearing at resident's R1 did not make any mention of this allegation when LPA asked what was wrong at the facility. LPA spoke to R1's sister who also did not mention this during interview. All staff interviewed denied the allegation. Most staff identified R1 as swearing at them when redirected.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4