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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701176
Report Date: 07/21/2025
Date Signed: 07/21/2025 12:48:40 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
07/18/2025 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20250718142715
FACILITY NAME:CISTERS LOVING CARE HOME IIFACILITY NUMBER:
342701176
ADMINISTRATOR:FUENTES, FLORINDAFACILITY TYPE:
735
ADDRESS:5316 NECTAR CIRCLETELEPHONE:
(916) 897-3834
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:4CENSUS: 4DATE:
07/21/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Florinda Fuentes, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff member shared client's confidential information
INVESTIGATION FINDINGS:
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On 07/21/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced regarding a complaint. LPA Campbell met with Administrator Fuentes and explained the purpose of the visit.

Regarding the allegation that a staff member shared client's confidential information, another facility notified the Department they had received confidential documents from Cisters Loving Care Hiome II . The Department then received images of these documents. The documents included MARS (Medication Administrator Records) for Resident 1 and Resident 2 (R1 and R2) When interviewed, Staff 1 (S1) confirmed they had provided MARs documents from Cister's Loving Care Home II to show another facility how Cister's II records medication information.
Based on LPA’s interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
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 2
Control Number 27-AS-20250718142715
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: CISTERS LOVING CARE HOME II
FACILITY NUMBER: 342701176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2025
Section Cited
CCR
80070(c)(1-2)
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Client Records(c) All information and records obtained from or regarding clients shall be confidential. (1) The licensee shall be responsible for .. the confidentiality of record contents. , the licensee and all employees shall not reveal or make available confidential information. This requirement is not met as evidenced by:
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Staff meeting will be conducted regarding resident privacy and staff will review the regulation and write a memo of understanding to be sent to LPA Campbell at renee.campbell@dss.ca.gov
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Based on interviews and record review, the licensee did not ensure the confidentiality of record contents and made available confidential information which poses an immediate Health Safety or Personal Rights risk to persons in care.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2