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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700961
Report Date: 08/20/2025
Date Signed: 08/20/2025 02:08:01 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
12/19/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20241219155944
FACILITY NAME:COMFORTS OF HOME TREASUREFACILITY NUMBER:
342700961
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:6997 TREASURE WAYTELEPHONE:
(916) 833-1493
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jackie ChanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
1) Questionable Death
2) Facility gave resident wrong medication.
INVESTIGATION FINDINGS:
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12
13
Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Comforts of Home Treasure RCFE on 8/20/25 at 1:10pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with administrator, Jackie Chan and together discussed the investigation details.
Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. The department obtained the death certificate for R1 which indicated R1 passed from natural causes and did not identify any medications or overdose resulting in R1's death. Additionally, the department reviewed R1's medication logs and found no errors in medication administration for R1. LPA reviewed other resident medication administration logs and observed no documented errors of medication administration. LPA conducted interviews with three staff members who all denied making or observing any medication errors for R1. Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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 4
Control Number 27-AS-20241219155944
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: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961
VISIT DATE: 08/20/2025
NARRATIVE
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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 Questionable Death and Medications are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with 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: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
12/19/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20241219155944

FACILITY NAME:COMFORTS OF HOME TREASUREFACILITY NUMBER:
342700961
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:6997 TREASURE WAYTELEPHONE:
(916) 833-1493
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jackie ChanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to report resident death.
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Comforts of Home Treasure RCFE on 8/20/25 at 1:10pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Jackie Chan and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. At the time the complaint was received LPA Velario checked the department files and did not observe any death report from the facility when the complaint was received. LPA Gould arrived at the facility and LPA did not observe any emails sent to LPA informing the department of R1's death. The facility administrator had a hard copy of R1's death report in the resident file but no report was sent to the department.

Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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-20241219155944
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: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961
VISIT DATE: 08/20/2025
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of reporting requirements is substantiated.

The department has already addressed the deficiency as part of a case management visit on 12/20/24. POC documents have already been provided and the deficiency has been cleared.

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

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4