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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701514
Report Date: 07/15/2025
Date Signed: 07/15/2025 11:14:17 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
04/23/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250423080638
FACILITY NAME:SUMERLIN GUEST HOME 2FACILITY NUMBER:
342701514
ADMINISTRATOR:CALDEIRA, MARIA SOCORROFACILITY TYPE:
740
ADDRESS:8667 SUMERLIN CT.TELEPHONE:
(916) 304-3575
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eric SerranoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff allow excluded individual to be present in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with house manager Eric Serrano and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review.

The California Department of Social Services (CDSS) received a report from the California Department of Health Care Services (DHCS), stating that two DHCS officials who were present in this facility on 4/17/25 observed an excluded person present. That person has been subject to a court order barring them from being present in any care facility licensed by the California Department of Social Services. The excluded individual asked the officials not to tell anyone that they were present in this facility, per an interview with a DHCS official. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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-20250423080638
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: SUMERLIN GUEST HOME 2
FACILITY NUMBER: 342701514
VISIT DATE: 07/15/2025
NARRATIVE
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In an interview, a facility manager (S1) admitted that the excluded person had been present in this facility. S1 said that this person was assisting with a transition after a recent change in ownership, and had been assisting with applying for the assisted living waiver program. S1 said they knew that the person was excluded and not allowed to be in any CDSS-licensed care facility.

The department has determined the following as it relates to the allegation that staff allowed an excluded individual to be present in the facility:

Based on interviews, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 87355(e)(2). Due to the presence of an excluded individual, an immediate civil penalty in the amount of $500 is hereby assessed. An exit interview was held with Serrano. Appeal rights and a copy of this report were left with Serrano.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250423080638
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: SUMERLIN GUEST HOME 2
FACILITY NUMBER: 342701514
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2025
Section Cited
CCR
87355(e)(2)
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"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: ... (2) Obtain a California clearance or a criminal record exemption as required by the Department or..." This requirement was not met as evidenced by:
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Licensee agrees to write a statement acknowledging that this person will no longer be present in this facility at any point in the future.
vincent.moleski@dss.ca.gov
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Based on interviews with staff and with DHCS personnel, an excluded individual, who is unable to obtain a criminal record clearance, was present in this facility with staff foreknowledge, which poses an immediate health, safety, and/or personal rights risk.
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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: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
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