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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701489
Report Date: 09/16/2025
Date Signed: 09/16/2025 02:24:31 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
09/08/2025 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20250908115645
FACILITY NAME:CASA DORISFACILITY NUMBER:
342701489
ADMINISTRATOR:ANI DARBINYANFACILITY TYPE:
740
ADDRESS:8533 LIQUID AMBER WAYTELEPHONE:
(916) 670-0370
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 4DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Haykush Harutyunyan, LicenseeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Due to a lack of staff, resident was left on the floor for an extended period of time
INVESTIGATION FINDINGS:
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On 09/16/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility at approximately 8:15 am to open and present findings for a complaint. LPA Campbell met with Haykush Harutyunyan, Licensee and explained the purpose of the visit.
Regarding the complaint that, resident was left on the floor for an extended period of time due to lack of staff, LPA Campbell interviewed C1, C2, F1 and F2. Per C1 and C2, C1 fell while going to the bathroom during the night and was unable to get up. C1 called for help but no staff came. When C2 woke up, both parties called for help and still no staff arrived. C2 then called F1 by phone. Per F1, C2 called them at approximately 6:30 am. At the time of the call, C2 stated, “We've been yelling for them to come and no one comes”. F1 called the facility and all calls went directly to voicemail or were not answered. F1 contacted F2 as well. Using their call logs, F1 and F2 were able to confirm that this incident occurred between approximately 6:45 am and 7:30 am. This does not include the time that C1 and C2 were unable to contact staff while C1 was incapacitated on the floor. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, 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: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20250908115645
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: CASA DORIS
FACILITY NUMBER: 342701489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2025
Section Cited
CCR
87464(f)(1)(5)
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Basic services shall at a minimum include:
Regular observation of the resident's physical and mental condition, as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by:
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LIcensees will provide a plan of action to ensure the deficiency will not occur again and submit a Memo of understanding to LPA Campbell for 87464 by the POC date.
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Staff were unavailable to provide regular observation of R1's physical conditions which poses an immediate Health, Safet and/or Personal 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: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2