347001643-4-23-2025-27-AS-CACL-DG8NUJ-20250430104623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001643
Report Date: 04/23/2025
Date Signed: 04/23/2025 03:11:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
04/15/2025 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20250415142426

FACILITY NAME:	DOSTY'S PRIVATE INCARE SERVICES IV		FACILITY NUMBER:	347001643
ADMINISTRATOR:	CAROLYN J. DOSTY		FACILITY TYPE:	735
ADDRESS:	2175 56TH AVENUE		TELEPHONE:	(916) 399-0287
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 6	DATE:	04/23/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Carolyn Dosty		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Personal Rights:
1) Staff threatened resident.
2) Staff did not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Dosty's Private Incare Services IV (ARF) on 4/23/25 at 1:00pm to inform the licensee of complaint allegations mentioned above.

During this investigation LPA Gould interviewed RP, S1, S2, S3, R2, R3, R4. R1 declined to speak with LPA despite several attempts and staff prompting (See confidential name list LIC-811 dated 4/23/25).

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. The alleged victim, (R1) refused to speak with LPA. LPA conducted interviews with three other residents and three staff members. All residents interviewed denied the allegations and denied ever witnessing any staff member threaten them of witnessed any other resident being threatened. All residents interviewed stated they are treated with respect and kindness. Report Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250415142426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: DOSTY'S PRIVATE INCARE SERVICES IV	FACILITY NUMBER: 347001643
	VISIT DATE: 04/23/2025

NARRATIVE

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LPA conducted file review and observed alleged victim has an extensive history of making false allegations including prior to their placement at this facility and ongoing false allegations against roommates and residents and other facility staff members.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

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