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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700872
Report Date: 10/15/2024
Date Signed: 10/15/2024 09:06:08 AM

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
06/06/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240606093404
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: DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
08:30 PM
MET WITH:TIME COMPLETED:
09:00 PM
ALLEGATION(S):
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Staff hit client
INVESTIGATION FINDINGS:
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On 10-15-24, Licensing Program Analyst (LPA) Renee Campbell visited the facility unannounced regarding a complaint opened on 09/06/24.
LPA Renee Campbell met with Roderick Luna, Direct Service Provider and explained the purpose of the visit.

Regarding the allegation that staff hit client, when interviewed, S2 stated, “I saw the motion of S1 being hit and when she was off balance because of it.” when S1 walked in front of C1 and C2. “But no, S1 did not hit C1 or C2”. After coming inside the facility, S1 told S2 and S3 that C2 hit them.
Both S2 and S3 then reported seeing a red area on S1’s arm.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation
is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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-20240606093404
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: MASON'S HOME, LLC
FACILITY NUMBER: 342700872
VISIT DATE: 10/15/2024
NARRATIVE
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Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence
to prove the alleged violation(s) did or did not occur, and therefore this allegation is unsubstantiated. Per California Code of Regulations (CCRs) –
Title 22, Division 6, no deficiencies cited. Exit interview was held and a copy of report was given to Roderick Luna. Appeal rights provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2