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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701031
Report Date: 07/10/2025
Date Signed: 07/10/2025 05:23:00 PM

Substantiated


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
05/21/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250521091205
FACILITY NAME:J. NAGTALON ADULT CARE SERVICES IIFACILITY NUMBER:
342701031
ADMINISTRATOR:WANDASAN, JUDITHFACILITY TYPE:
735
ADDRESS:8155 SAINT BRENDAN PLACETELEPHONE:
(916) 524-2717
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:4CENSUS: 3DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Judith Wandasan TIME COMPLETED:
06:05 PM
ALLEGATION(S):
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Staff are inappropriately locking the facility grounds
Staff have inadequate record keeping for a client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Tamayo made an unannounced inspection to J. Nagtalon Adult Care Services II ARF on 7/10/2025 to conclude the investigation of the above allegations and to deliver the findings. LPA Cynthia Tamayo met with staff, Judith Wandasan and together discussed the investigation details.

Based on LPA observations and record review during the investigation process and statements obtained during the investigation process, LPA Tamayo was able to corroborate the allegations. It was reported the padlock on wooden gate the gate could not easily be opened as a lock was placed in the self-latching mechanism which made exiting inaccessible. This allegation was corroborated by an observed a photograph of the exterior gate which had a keyed padlock on the self latching mechanism. On 5/27/25, S3 stated the lock was placed for security reasons and because R2 has a history of AWOL/elopement. S3 immediately removed the lock that on the emergency exit gate.
continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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-20250521091205
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: J. NAGTALON ADULT CARE SERVICES II
FACILITY NUMBER: 342701031
VISIT DATE: 07/10/2025
NARRATIVE
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S3 self-admitted the gate was locked during Alta Regional Center visit with Service Coordinator (SC2) on March 20, 2025 whom observed the gate latch on the wooden gate exit in the backyard. On 5/27/25 and 7/10/25 LPA conducted a walk through of the facility grounds and inspected the emergency exit along the side of the home, LPA observed no obstructions leading to the back gate and there was no lock on the gate self latching .

LPA reviewed resident files and medication administration records. LPA observed one resident (R1's) file was incomplete and did not include all required documents. LPA did not observe an admission agreement, emergency information, personal rights forms, needs and services plan or consent forms in R1's file. LPA only observed a physicians report and pre-placement appraisal in R1's file. Additionally, LPA observed errors in documentation of medication administration for multiple residents. LPA observed some medications had not been marked as administered or were marked as given daily when only administered once per week.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegations of staff are inappropriately locking the facility grounds are substantiated, as a lock was placed on the emergency exit gate and poses a health and safety risk to residents, staff and visitors.

The following deficiency 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 home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250521091205
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: J. NAGTALON ADULT CARE SERVICES II
FACILITY NUMBER: 342701031
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2025
Section Cited
CCR
80087(c)
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80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement was not met
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Facility staff has removed the lock from the exterior gate. Staff will not lock gates and agreed to ensure the gate can be easily opened from inside the back yard and will ensure the gate can be easily opened and not obstructed. Licensee had staff complete training with Alta regional center on 6/10/25 and 6/12/25.
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as evidenced by observations the gate latch is on the exterior of the gate and could not easily be opened as a string that attached to the lock is no longer accessible inside the gate. LPA also observed the pavers below the gate are obstructing opening the emergency exit gate which poses an immediate health, safety or personal rights risk to residents in care.
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Licensee will submit understanding of regualtaion 80087 Buildings and Grounds to LPA Cynthia Tamayo by 7/25/2025
Type B
07/25/2025
Section Cited
CCR
80068(a)(1)
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80068 Admission Agreements (a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative ...

This requirement was not met
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Facility staff will review LIC 311 C and complete all missing resident records.
Facility has agreed to provide a written plan of correction with the specific steps the administrator will take to ensure all resident files are complete, signed and present at the facility at all times. POC due date is 7/25/25.
ubmit them to LPA Cynthia Tamayo.
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Admission agreement was not signed by client and/or client's authorized representative for R3. Aditionally, Client/Resident Personal Property and Valuables (LIC 621) and Consent for Emergency Medical Treatment (LIC 627C) is missing or incomplete for R2-R4.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
05/21/2025 and conducted by Evaluator Cynthia Tamayo
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250521091205

FACILITY NAME:J. NAGTALON ADULT CARE SERVICES IIFACILITY NUMBER:
342701031
ADMINISTRATOR:WANDASAN, JUDITHFACILITY TYPE:
735
ADDRESS:8155 SAINT BRENDAN PLACETELEPHONE:
(916) 524-2717
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:4CENSUS: 3DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Jesusa (Susan) Nagtalon TIME COMPLETED:
06:05 PM
ALLEGATION(S):
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Staff did not properly report an incident regarding a client
Staff denied a client access to food while in care
INVESTIGATION FINDINGS:
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This is an amended version of the original report created on 7/10/25
Licensing Program Analyst (LPA) Cynthia Tamayo made an unannounced inspection to J. Nagtalon Adult Care Services II ARF on 7/10/2025 to conclude the investigation of the above allegations and to deliver the findings. LPA Cynthia Tamayo met with staff, Judith Wandasan and together discussed the investigation details.

Based on LPA observations and record review during the investigation process and statements obtained during the investigation process, LPA Tamayo was not able to corroborate the allegations.
LPA Tamayo conducted record review for R1 and verified facility reported the Death of a resident following Title 22 regulations. Date of Death for R1 was 5/18/25, an LIC 624(A) was received by the Regional Office on 5/19/25. On 5/27/25 and 7/10/25 LPA conducted a walk through of the facility grounds observed residents foods to be accessible to residents in care. LPA observed 2-day perishables and 7-day non-perishables. LPA observed R3 to open the pantry closet located in the hallway and grab snacks to eat. LPA interviewed three (3) residents in care (R2-R4).

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 allegation of 'staff did not properly report an incident regarding a client' and 'staff denied a client access to food while in care' 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 administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4