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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701176
Report Date: 10/20/2025
Date Signed: 10/20/2025 11:36:12 AM

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
10/06/2025 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251006132945
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:
10/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pedro BunaganTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff used restraints on resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation finding. LPA Valerio was met by Lead Staff member Pedro Bunagan, and explained the purpose of the visit.

The following has been determined as it relates to the aforementioned allegation.

On 10/06/2025, Alta California Regional Center conducted an unannounced visit to ensure the health and safety of the residents in care. No immediate health or safety risks were noted during the visit.

On 10/06/2025, the Department was informed that a staff used sticks to prevent a resident, Resident 1 (R1), from moving around in R1's wheelchair. Five (5) pictures were provided.

Continues on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
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-20251006132945
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
VISIT DATE: 10/20/2025
NARRATIVE
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LPA Valerio reviewed five (5) photos. Photo 1 is a picture of an unidentified staff member facing the kitchen cabinets. In the photo, there is R1 sitting in a wheelchair behind the staff member. Photo 2 is a photo of R1's back in the wheelchair showing a cloth around R1's torso and then tied around the back of the wheelchair. There is a pink circle around the knotted clothing item appearing to hold the cloth together. Photo 3 is a picture of R1 sitting in the wheelchair with R1's shirt back over the handlebars and a sweater wrapper around the torso. Photo 3 shows two long sticks that are lodged through R1's wheelchair wheels. Photo 4 is a picture of the side profile of two residents residing in the home. Photo 5 is a close-up picture of R1's wheelchair wheels. The picture shows two sticks placed through the wheels.

LPA Valerio observed the facility on 10/07/2025. Based on LPA's observation of the facility, the kitchen cabinets in the photos match the kitchen at the facility. LPA also compared the residents pictured in the photos with the residents present in the home. Two (2) out of two (2) residents were present during LPA's visit.

LPA Valerio reviewed facility documentation. According to R1's Individual Program Plan and LIC 602 Physician's Report, R1 is able to ambulate without an adaptive device. R1 does not have documentation to support the use of a wheelchair.

According to the facility's program design, the facility is not licensed or vendorized to use restraints of any kind for the residents in care under any circumstances. The facility is vendorized through Alta California Regional Center as a level 4i home.

LPA Valerio interviewed three (3) out of the four (4) residents in care. Residents express feeling safe, enjoy living at the home, and did not indicate any concerns.


Continues on LIC 9099-C, page 3..
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20251006132945
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
VISIT DATE: 10/20/2025
NARRATIVE
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LPA Valerio interviewed ten (10) staff. Based on all staff interviews, all staff denied ever observing, hearing, or personally using restraints towards any of the residents.

Based on the interviews with staff and residents, LPA Valerio cannot determine which staff member(s) committed a violation of the residents' personal rights.  Although a picture was submitted of an individual's back, the picture cannot identify the staff member nor can it identify whether the alleged staff member committed the act. However, the photos submitted do show sufficient evidence that R1 was restrained and confined to a wheelchair with the use of sticks inserted through the wheels of the wheelchair, a towel/ cloth-like material tied around the resident, and the resident's shirt draped over the back of the wheelchair back. 

Based on the review of the photos provided, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.  California Code of Regulations (Title 22, Division 6, Chapter 1) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted with Lead Staff member Pedro Bunagan, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20251006132945
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: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2025
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights(a)...each client shall have personal rights which include...:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature..
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Licensee stated they did training on 10/12/2025 regarding Client Rights in-service training with all staff. LPA Valerio to recieve a copy of the training along with the sign-in sheet with all the staff names that attended the training.
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This requirement was not met as evidenced by: Based on records review of pictures, the licensee did not ensure R1 was free from being tied to the wheelchair by staff and restrained from moving freely, which poses an immediate personal rights risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4