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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701631
Report Date: 12/18/2025
Date Signed: 12/18/2025 10:55:33 AM

Unfounded


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
12/15/2025 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251215151057
FACILITY NAME:AUTUMN GROVE SENIOR LIVINGFACILITY NUMBER:
342701631
ADMINISTRATOR:ALBASON, ANDREFACILITY TYPE:
740
ADDRESS:10167 MOSAIC WAYTELEPHONE:
(916) 879-6912
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alicia MorenoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not fingerprint cleared to provide care and supervision to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/18/25, Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit. LPA met with Alicia Moreno and a brief interview followed.

LPA requested and reviewed staff files all files were complete and all staff who were currently at the facility were fingerprint cleared, also all staff that had files at the facility were cleared. LPA also interviewed R1-R2 and S1-S2. Based on documents reviewed and interviews with staff the above allegation is UNFOUNDED. The department has determined that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview and copy of report given.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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