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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701631
Report Date: 02/06/2026
Date Signed: 02/06/2026 11:24:27 AM

Unsubstantiated


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-20251215150153
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:
02/06/2026
UNANNOUNCEDTIME BEGAN:
09:00 PM
MET WITH:ALBASON, ANDRETIME COMPLETED:
11:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not have required training
Staff did not seek timely medical care for resident
Staff leave resident in soiled diapers/linins for an extended period of time
Staff did not follow physician's orders
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/06/26, Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to deliver fingings for the above allegation. LPA identified herself upon arrival, stated the purpose of the visit.

Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

There are no deficiencies cited per California Code of Regulations, TITLE 22.



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

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
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
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-20251215150153

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:
02/06/2026
UNANNOUNCEDTIME BEGAN:
09:00 PM
MET WITH:ALBASON, ANDRETIME COMPLETED:
11:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is malodorous
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/06/26, Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to deliver fingings for the above allegation. LPA identified herself upon arrival, stated the purpose of the visit.
Based on LPA observation and tour of the facility on mutiple occations the allegation the Facility is malodorous is UNFOUNDED. The complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.

There are no deficiencies cited per California Code of Regulations, TITLE 22.


An exit interview was conducted, and a copy of this report was provided.





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: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2