345920017-1-8-2026-59-AS-LCRR-DQ9QGG-20260112110929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920017
Report Date: 01/08/2026
Date Signed: 01/08/2026 03:35:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
07/11/2025 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20250711145403

FACILITY NAME:	ILLINOIS HOME, LLC		FACILITY NUMBER:	345920017
ADMINISTRATOR:	SAMSON, DEXTER C.		FACILITY TYPE:	737
ADDRESS:	5035 ILLINOIS AVE		TELEPHONE:	(916) 206-9433
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	4	CENSUS: 4	DATE:	01/08/2026
		UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Dexter Samson and Jasmin Samson, Administrators		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff are not ensuring that residents are hydrated

Facility staff are not following physician's orders

Facility is not providing activities for the residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the faciltiy and met with Administrators, Dexter Samson and Jasmin Samson, to deliver findings regarding the complaint allegations listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Facility staff are not ensuring that residents are hydrated

Relevant party reported concerns that the facility was not ensuring that resident (R1) was kept hydrated after sustaining a burn at their day program on July 3, 2025.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

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 4

Control Number 59-AS-20250711145403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ILLINOIS HOME, LLC	FACILITY NUMBER: 345920017
	VISIT DATE: 01/08/2026

NARRATIVE

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Interviews with staff members S1, S2, S3, S4, S5 and Administrators indicated that the facility ensures that the residents are hydrated, including R1. S1, S2, S3, S4, and S5 stated that they give R1 fluids throughout the day. Interviews with staff indicated that they have never witnessed any residents at the facility to be dehydrated.

LPA observed fluid intake for R1 to be documented at the facility from July 19, 2025 to August 10, 2025 and observed fluids to be offered to R1 throughout the day. LPA reviewed text message correspondence from Administrators sent to R1's authorized representative dated July 7, 2025 indicating that R1 was transferred to emergency services "as a precautionary measure" to ensure that R1 did not become dehydrated. LPA observed medical records for R1 regarding medical visits on July 3, 2025, July 7, 2025, and August 2, 2025. LPA also observed Physician Visit Documentation for R1's medical visits conducted on July 15, 2025 and July 25, 2025. LPA did not observe any indication that R1 was dehydrated during medical visits.

Allegation: Facility staff are not following physician's orders

Relevant party reported concerns that facility was not ensuring to follow physician's orders regarding R1's wounds sustained from their day program on July 3, 2025.

Interview with Administrators indicated that the facility was following physician's orders regarding medications provided to R1 regarding the wounds sustained from their day program. Interviews with staff members S1, S2, S3, and S4 indicated that nurses at the facility are responsible for providing medications to the residents in care. Interview with S5 indicated that they followed doctor's orders regarding the medications prescribed to R1 to address wounds sustained from their day program. S5 indicated that they ensured that R1's wounds were cleaned and dressed appropriately. S5 indicated that R1's wounds healed well, which was observed during follow-up medical visits. LPA observed medical records for R1 regarding medical visits on July 3, 2025, July 7, 2025, and August 2, 2025. LPA observed R1 to be prescribed silver sulfadiazine to address wounds during July 3, 2025 visit. Medical records for visit conducted on July 7, 2025 indicates the following: "Presentation is overall reassuring. I do not see any signs of acute infection. I do see extensive epidermal sloughing. The dermis appears to be intact. No cellulitis. No purulent drainage. Patient is in no acute distress."
** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20250711145403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ILLINOIS HOME, LLC	FACILITY NUMBER: 345920017
	VISIT DATE: 01/08/2026

NARRATIVE

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LPA observed bacitracin was prescribed following medical visit on July 7, 2025. LPA observed Office/Clinic Notes for medical visit on July 8, 2025 indicating R1 to stop bacitracin and continue silver sulfadiazine as R1 "responded to Silvadene cream." LPA observed Physician Visit Documentation dated July 15, 2025 regarding burn injury follow-up, indicating that R1 should continue silver sulfadiazine. LPA observed Physician Visit Documentation dated July 25, 2025 regarding evaluation, indicating that R1 should discontinue silver sulfadiazine. LPA observed Daily Medication Log for R1 for the month of July 2025 and observed silver sulfadiazine and bacitracin administered to R1 in accordance with doctor's orders. Physician Visit Documentation for July 25, 2025 visit indicated that R1 receive Aquaphor for two (2) weeks. LPA observed Aquaphor Log Form for R1 and observed R1 received Aquaphor from July 26, 2025 to August 9, 2025. LPA observed skin check for R1 to be "normal" during medical visit on August 2, 2025 according to medical records.

Allegation: Facility is not providing activities for the residents in care

Relevant party reported concerns regarding facility not ensuring that R1 was participating in activities after discontinuing services from day program.

Interviews conducted with staff members S1, S2, S3, S4, S5, and Administrators indicated that they are providing activities to the residents in care and they have no concerns regarding the facility providing activities. Administrator Jasmin indicated that R1 tends to have a short attention span and takes breaks often during activities. S1, S2, S3, S5 and Administrators stated that R1 was participating in activities after the incident regarding their burn on July 3, 2025. Staff interviews indicated that activities provided included physical activities, indoor games, toys, puzzles, and outings. LPA obtained and reviewed Daily Schedule for R1 from July 5, 2025 to August 10, 2025 and observed R1 participated in multiple activities, including outdoor and indoor activities, toys, games, puzzles, and outings. LPA observed pictures of R1 participating in multiple outings. During visits conducted on July 15, 2025, September 5, 2025, December 30, 2025, and January 8, 2026, LPA observed residents participating in activities at the facility. LPA observed provisions for activities present at the facility and the space to provide activities during visits.

** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20250711145403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ILLINOIS HOME, LLC	FACILITY NUMBER: 345920017
	VISIT DATE: 01/08/2026

NARRATIVE

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Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a 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.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC9099 (FAS) - (06/04)

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