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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920017
Report Date: 03/14/2025
Date Signed: 04/17/2025 03:28:23 PM

Substantiated


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
03/11/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250311124856
FACILITY NAME:ILLINOIS HOME, LLCFACILITY NUMBER:
345920017
ADMINISTRATOR:SAMSON, DEXTER C.FACILITY TYPE:
737
ADDRESS:5035 ILLINOIS AVETELEPHONE:
(916) 206-9433
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:4CENSUS: 4DATE:
03/14/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Dexter C. Samson & Jasmin Samson, AdministratorsTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Licensee does not ensure staff are adequately trained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrators, Dexter C. Samson and Jasmin Samson, to open a complaint investigation into the allegation listed above.

During today's visit, LPA reviewed records pertinent to the investigation.

*** The findings for the following complaint report were changed and a new 9099 now supersedes it. New findings can be found on subsequent 9099 ***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
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 2
Control Number 59-AS-20250311124856
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: 03/14/2025
NARRATIVE
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*** The findings for the following complaint report were changed and a new 9099 now supersedes it. New findings can be found on subsequent 9099 ***
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2