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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920062
Report Date: 08/11/2026
Date Signed: 08/11/2026 10:17:24 AM

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
08/03/2026 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20260803111655
FACILITY NAME:BLESSED HOMECARE 3FACILITY NUMBER:
345920062
ADMINISTRATOR:ARAMBULO, LERIZAFACILITY TYPE:
740
ADDRESS:6350 SAMOA WAYTELEPHONE:
(209) 834-4040
CITY:CARMICHAELSTATE: ZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
08/11/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Baby QuinteroTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Resident eloped from facility
Facility failed to report elopement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to open the investigation into allegations listed above. LPA met with Baby Quintero,during today’s visit.

During today's inspection LPA conducted interviews, toured the facility and reviewed records pertinent to the investigation.

**Continued on 9099-C page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
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
Control Number 59-AS-20260803111655
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: BLESSED HOMECARE 3
FACILITY NUMBER: 345920062
VISIT DATE: 08/11/2026
NARRATIVE
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Resident eloped from facility

Interviews conducted with staff indicated that Resident R1 turned off the front door alarm and walked out the front door of the facility on 07/25/2026 while staff were assisting another resident. R1 was found by staff across the street from the facility. Staff called emergency services for R1 as they had fallen. Documents reviewed indicated that R1 has a diagnosis of dementia and is able to ambulate with little to no assistance. R1 does not have a history of wandering or elopement. Therefore, the allegation resident eloped from facility is substantiated.

Facility failed to report elopement

Interviews conducted with staff indicated that an incident report was not completed and sent to the Department. Hospice services and R1’s family were notified. Therefore, the allegation resident eloped from facility is substantiated.

Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20260803111655
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: BLESSED HOMECARE 3
FACILITY NUMBER: 345920062
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2026
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include ... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Licensee will conduct a training on reporting requirements and submit materials to CCL by POC due date.
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This was not met by evidenced by:
R1 eloped from the facility on 07/25/2026 but it was not reported to the Department
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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.
SUPERVISOR'S NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3