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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 03:50:12 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:
04/17/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dexter C. Samson, AdministratorTIME COMPLETED:
02:00 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 faciltiy and met with Administrators, Dexter Samson and Jasmin Samson, to deliver findings regarding the complaint allegation listed above.

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

Allegation: Licensee does not ensure staff are adequately trained

Relevant party reported that staff member (S1) had not completed their required training to work as a Direct Care Staff (DSP) at the facility.

** Report continued on 9099-C **
Substantiated
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 3
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: 04/17/2025
NARRATIVE
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On March 10, 2025, LPA received a Facility Action Report (FAR) generated by Alta California Regional Center (ACRC) on the same day to address violations per Title 17 regulations. Information on the FAR is as follows: "ACRC completed a quarterly quality assurance review on 3/3/25. ACRC audited the past quarters staffing schedule who have not completed Registered Behavior Technician (RBT) certification within the first year of employment...Per the 8/7/24 Facility Action Report (FAR) [S1 and staff member S2] were two of the staff named in the Corrective Action Plan (CAP)." Interviews with Administrators confirmed that S1 and S2 did not obtain RBT certification per FAR received.

LPA reviewed facility's Plan of Operation on file with the Department. Facility's Plan of Operation states the following: "Direct Care Staff Minimum Qualifications: (...) Have six (6) months prior experience providing direct care to individuals with developmental disabilities and become a Registered Behavior Technician within twelve (12) months of initial employment." Interview with Administrators confirmed that S1 and S2 work at the facility as DSPs.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

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: 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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
80022(k)
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80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 80022 and submit statement to LPA by POC due date of 5/02/2025.
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Based on LPA's observations and records reviewed, the facility did not ensure staff were receiving RBT certification in accordance with facility's Plan of Operation, which poses a potential health, safety, and personal rights risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3