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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920017
Report Date: 04/17/2025
Date Signed: 04/17/2025 04:09:40 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
12/18/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241218151542
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:
04/17/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dexter C. Samson, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff are mismanaging residents' medications
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 allegation listed above.

During the investigation, LPA conducted interviews, conducted two (2) medication counts, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Facility staff are mismanaging residents' medications

Relevant party reported that facility is mismanaging resident R1's medications at the care home.

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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-20241218151542
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: 04/17/2025
NARRATIVE
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Interviews with staff members S1, S2, S3, S4, and S5 indicated that they have not witnessed residents' medications being mismanaged at the facility. Administrator Jasmin stated that R1 received a prescription of five (5) mg Melatonin with a doctor's order stating as needed as a PRN sometime in September 2023. Administrator Jasmin stated that medication was corrected to a ten (10) mg routine medication after being refilled. LPA observed R1's Physician Order Sheet dated June 29, 2023 which shows that Melatonin was prescribed to R1 as a ten (10) mg routine medication. Administrator stated that five (5) mg Melatonin for R1 was destroyed at a pharmacy and signed off by a pharmacy. LPA observed R1's Centrally Stored Medication Form (CSM) which showed that five (5) mg Melatonin was administered one (1) tab a day until prescription was refilled, in which five (5) mg medication was destroyed. Records do not indicated that more than one (1) tab of Melatonin was administered.

On December 19, 2024, LPA arrived at the facility and conducted a medication count for R1, comparing the resident’s CSM and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA observed emptied bubble packs stored since September 2024 with dates in which each tab was administered for R1. LPA observed no medications were refused. LPA observed medications given as prescribed. On March 14, 2025, LPA arrived at the facility and conducted a medication count for residents R1, R2, and R3, comparing each resident’s CSM and MAR with medications centrally stored for the resident. LPA was joined by Local Long-Term Care Ombudsman (LTCO) during medication count. For R1, LPA & LTCO observed emptied bubble packs stored since September 2024 with dates in which each tab was administered. LPA & LTCO observed no medications were refused and observed medications given as prescribed. LPA did not observe any errors when comparing medication count with CSMs for R2 and R3. LTCO confirmed LPA's findings regarding medication count during visit.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is 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 was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2