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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700872
Report Date: 08/03/2023
Date Signed: 08/03/2023 02:55:13 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
07/31/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230731090207
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:
08/03/2023
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Sally WongTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Personal Rights:
1) Staff are mistreating a client while in care.
2) Staff are not properly feeding a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Mason's Home LLC on 8/3/23 at 1:10pm to inform the licensee of complaint allegations mentioned above and to deliver findings.

During this investigation LPA Gould interviewed S1, R1, R2, A1 and Reporting Party (See confidential name list LIC-811 dated 8/3/23). LPA reviewed documentation of resident's food refusal which predates the complaint received by the department. LPA observed communication with alta regional center and ombudsperson describing behaviors of alleged victim including food refusal. LPA interviewed R1 who denied being mistreated by staff members. LPA then asked about breakfast and why R1 was refusing. R1 states the food was always the same as a reason for refusing. LPA observed pictures taken by staff which showed a variety of foods being presented to R1 and documented refusal of food (specifically breakfast). LPA reviewed resident weight record and observed no significant changes on R1's weight record.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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 2
Control Number 27-AS-20230731090207
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: 08/03/2023
NARRATIVE
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Per R1's Individual Program Plan (IPP) reviewed by LPA, R1 will make up stories and allegations to get needs met. LPAs review of file indicates the need resident is trying to have met is being moved to a new facility closer to the bay area and family. Per IPP a new placement is currently being evaluated/determined by regional center.

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: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2