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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700872
Report Date: 02/12/2025
Date Signed: 02/12/2025 03:50:14 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
09/25/2024 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20240925204639
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:
02/12/2025
UNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Sally WongTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not address resident's change in condition.
Staff did not meet resident's nutritional needs.
INVESTIGATION FINDINGS:
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On 2/12/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a follow up complaint visit regarding the allegations noted above. LPA intially met with staff on duty and stated the purpose of the visit. The Administrator, Sally Wong (AD) was notified of this visit and arrived shortly after. Upon arrival, 1 resident was present with 3 staff on duty. The other 3 residents in care were out in the community.

The investigation into the allegation that staff did not address resident's change in condition consisted of record reviews and interviews. Interviews with staff members on duty (S1, S2, and S3) revealed that R1 was admitted with a history of stroke and required assistance with mobility. Staff reported that R1 was weighed with their wheelchair upon admission to this facility, noting that R1's weight was not accurate. Staff added that R1's real weight was less than what was reported. Staff also stated that R1's condition had improved during their stay at this facility, including their ability to walk with assistance.
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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
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 3
Control Number 27-AS-20240925204639
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: 02/12/2025
NARRATIVE
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Furthermore, staff provided regular care, including meal assistance, neighborhood walks, and the use of two staff for showering due to R1's tendency to kick. Administrator Sally Wong also provided insight, stating that R1's weight loss concerns were discussed with a physician, who acknowledged that weight gain might take some time. R1 had regular medical follow-ups, including a visit on 6/17/24 where unintentional weight loss was addressed. Interviews also revealed that R1's appetite was noted to be good. Further, no seizure history was reported by R1's family or medical records prior to moving to this facility. Record review indicated that an incident of seizure occurred in 9/13/24, which was addressed with medical intervention, including emergency transport and seizure medication. Record reviews corroborated these findings, confirming that R1’s weight remained stable, with minor fluctuations documented in facility records.

While a seizure incident occurred on 9/13/24, there was not enough evidence to indicate that staff failed to respond appropriately, as the incident was followed by prompt medical consultation and emergency action. Additionally, R1’s physician prescribed dietary adjustments, including prescribing ensure to address weight loss and medication to address seizure management. Based on the information gathered, the facility and staff took measures in addressing R1’s needs, including medical consultations, ongoing support with mobility and feeding, and response to a change in condition (seizures and weight loss), therefore, this allegation was UNSUBSTANTIATED.
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The investigation into the allegation that staff did not meet R1's nutritional needs consisted of review of records and interviews with staff. Staff members (S1, S2, and S3) confirmed that R1 had a good appetite and that they assisted with meals, including chopping food to accommodate R1’s lack of teeth. It was also noted that R1 was on a special minced and moist diet due to dysphagia. Administrator Sally Wong further corroborated that R1's appetite was consistently good, and R1 ate the same amount as the other residents.

Additionally, R1's physician reports indicated that R1 had a stable weight range since admission, with minor fluctuations. At the time of admission, R1’s weight was recorded at 79 lbs, and throughout their stay, it remained relatively stable, reaching 80 lbs by 6/7/24. Concerns regarding R1’s weight were addressed in a timely manner, and on 9/23/24, after a blood test, R1 was prescribed Ensure supplements to help with weight gain. While R1 experienced unintentional weight loss, this was managed with medical guidance, and R1's doctor did not attribute this to any issues related to the facility’s care.



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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240925204639
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: 02/12/2025
NARRATIVE
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Based on the information gathered, the allegation that facility did not meet resident's nutritional needs was UNSUBSTANTIATED. The facility staff took measures to address R1's dietary needs by assisting with meals and providing a soft, chopped diet.

Note that a finding that is unsubstantiated means that 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.

Per California Code of Regulations (CCRs), Title 22, Division 6, no deficiencies cited. Exit interview was held and a copy of report and appeal rights were provided.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3