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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701631
Report Date: 03/11/2026
Date Signed: 03/11/2026 02:25:16 PM

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
03/02/2026 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260302165112
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:
03/11/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Andre AlbasonTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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5
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9
Staff illegally evicted a resident in care.
INVESTIGATION FINDINGS:
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5
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13
On 03/11/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an complaint visit. LPA Pascua was greeted by Staff Member (SM), Eljane Navalon and explained the purpose of the visit. LPA Pascua asked SM Navalon to contact the Facility Designated Administrator (FDA), Andre Albason and notify them that CCL was present at this time. LPA Pascua was able to speak with FDA Albason via telephone and identify the purpose of the visit. FDA Albason stated that they would arrive at the facility within 20 minutes. At 1:15pm, FDA Albason arrived at the facility.
Current census was 5. A brief interview with FDA Albason was conducted.
During the course of this visit. LPA Pascua conducted interviews, reviewed facility records and toured the facility.
It was alleged that staff illegally evicted resident in care. It was learned that the facility resident is still residing at the facility and the facility has not issued an eviction notice at this time. 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.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
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 3
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
03/02/2026 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260302165112

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:
03/11/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Andre AlbasonTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent a resident from eloping from the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/11/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an complaint visit. LPA Pascua was greeted by Staff Member (SM), Eljane Navalon and explained the purpose of the visit. LPA Pascua asked SM Navalon to contact the Facility Designated Administrator (FDA), Andre Albason and notify them that CCL was present at this time. LPA Pascua was able to speak with FDA Albason via telephone and identify the purpose of the visit. FDA Albason stated that they would arrive at the facility within 20 minutes. At 1:15pm, FDA Albason arrived at the facility.

Current census was 5. A brief interview with FDA Albason was conducted.
During the course of this visit. LPA Pascua conducted interviews and reviewed facility records.
Based on interviews conducted, it was learned that on 02/02/2026, the facility was bringing in groceries and left the door open. Shortly after, staff witnessed R1 walking outside of the door and was able to redirect the resident back into the facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
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 3
Control Number 27-AS-20260302165112
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: AUTUMN GROVE SENIOR LIVING
FACILITY NUMBER: 342701631
VISIT DATE: 03/11/2026
NARRATIVE
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32
A review of the facility records were conducted, it was observed that this resident did not have a tendency of wandering from their pre-appraisal however communication was conducted to inform the residents responsible party of the incident. Since the incident, facility administrator has implemented staffing and increased supervision to ensure the health and safety of the resident in care.

Based on the information gathered, there is not sufficient evidence to prove that the facility staff did not prevent a resident from eloping from the facility.

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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3