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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004525
Report Date: 09/11/2025
Date Signed: 09/11/2025 03:38:31 PM

Substantiated


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
02/11/2025 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20250211121813
FACILITY NAME:EMBASSY FOUNTAIN INC. #2FACILITY NUMBER:
347004525
ADMINISTRATOR:NITTA, LEILANI M.FACILITY TYPE:
735
ADDRESS:10021 MOSAIC WAYTELEPHONE:
(916) 647-4267
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
09/11/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leilani Nitta, AdministratoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not seek timely medical care for client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to the facility to deliver complaint findings. LPA Campbell met with Leilani Nitta, Administrator, and explained the purpose of the visit.

The department has determined the following as it relates to the aforementioned allegation. The investigation consisted of an interview with an outside agency, interviews with staff, and a review of facility records.

According to an outside agency, the facility did not submit an incident report regarding a fall that occurred with Resident 1 (R1) until the outside agency conducted an onsite visit. During the onsite visit, the outside agency learned that R1 fell on 10/24/2024 but was not sent to the hospital until 10/26/2024.

Continues on LIC 9099 - C…
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
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 5
Control Number 27-AS-20250211121813
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: EMBASSY FOUNTAIN INC. #2
FACILITY NUMBER: 347004525
VISIT DATE: 09/11/2025
NARRATIVE
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Continued from LIC 9099

According to a review of facility records, an incident report dated 10/26/2024 disclosed that R1 fell while using the restroom. R1 was assisted back up and back to R1's room. R1 later expressed pain but staff checked mobility and touched area of pain on R1. R1 did not show reaction or pain. On 10/25/25, R1 woke up complaining of leg pains. The house manager arrived at the facility and observed R1 able to stand with signs of possible soreness. On 10/26/24, R1 was observed to be more lethargic, which then led the manager to tell staff to send R1 to the ER.

Based on facility records, R1 sustained a hip fracture from the fall. R1 underwent a partial hip replacement and was transferred to a rehabilitation facility.

According to an interview with S1, S1 was not present when R1 initially fell. S1 was present on 10/25/2024. S1 stated looking back S1 should have sent R1 out on 10/25/24. At the time, S1 reported that R1 could not verbally communicate the amount of pain. S1 observed R1 to stand up as R1 normally would. S1 stated R1 is a fall risk but it is not indicated because they are frequent due to R1's health condition. S1 stated the facility sent R1 out when they observed a change of condition.

LPA Valerio attempted to interview S2; however, S2 did not return LPA's call. Based on facility records. S2 worked during the time R1 experienced the fall on 10/24/24.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 1) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250211121813
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: EMBASSY FOUNTAIN INC. #2
FACILITY NUMBER: 347004525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2025
Section Cited
CCR
80072(a)(9)
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80072 Personal Rights (a) …each client shall have personal rights which include, but are not limited to, the following: (9) To receive or reject medical care… This requirement was not met as evidenced by:
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Administrator will confirm registration for staff training in Fall Prevention and or Seizure First Aid Training and provide a sign in sheet with the signatures of all personnel on staff who attend by the POC due date.
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Based on interviews and records review, the licensee did not ensure to send R1 out to the emergency room after R1 sustained a fall while living at Embassy Fountain Inc. #2, which poses an immediate health, safety, and personal rights risk to 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: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/11/2025 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20250211121813

FACILITY NAME:EMBASSY FOUNTAIN INC. #2FACILITY NUMBER:
347004525
ADMINISTRATOR:NITTA, LEILANI M.FACILITY TYPE:
735
ADDRESS:10021 MOSAIC WAYTELEPHONE:
(916) 647-4267
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
09/11/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leilani Nitta, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff left client unattended resulting in a fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to the facility to deliver complaint findings. LPA Renee Campbell met with Leilani Nitta, Administrator, and explained the purpose of the visit.

The department has determined the following as it relates to the aforementioned allegation. The investigation consisted of an interview with an outside agency, interviews with staffi, and a review of facility records.

According to a review of facility records, an incident report dated 10/26/2024 disclosed that R1 fell while using the restroom. R1 was assisted back up and back to R1's room. R1 later expressed pain but staff checked mobility and touched area of pain on R1. R1 did not show reaction or pain. On 10/25/25, R1 woke up complaining of leg pains. The house manager arrived at the facility and observed R1 able to stand with signs of possible soreness. On 10/26/24, R1 was observed to be more lethargic, which then led the manager to tell staff to send R1 to the ER. Continues on LIC 9099 - C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250211121813
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: EMBASSY FOUNTAIN INC. #2
FACILITY NUMBER: 347004525
VISIT DATE: 09/11/2025
NARRATIVE
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Continued from LIC 9099

According to a review of facility records, R1's Individual Program Plan (IPP) dated 07/31/2024 indicated an objective for hygiene, which stated " [R1's] disabilities keep [R1] from bathing and brushing properly. Staff continue to do hand over hand for all of [R1's] personal needs."

According to a review of facility records, R1's LIC 602 Physician Report dated 08/21/2024 indicated that R1 is "occasional" for able to communicate, able to care for all personal needs, able to bathe self with assistance, able to care for own toilet needs, able to ambulate without assistance, and does not need constant medical supervision.

According to an interview with S1, R1 always goes to the bathroom by themselves. R1 has never needed assistance from all the time that R1 has lived at the home. R1 has lived with the licensee for many years. S1 stated that the staff have worked with R1 for over 10 years and knows R1 really well.

LPA Valerio attempted to interview S2; however, S2 did not return LPA's call. Based on facility records. S2 worked during the time R1 experienced the fall on 10/24/24.

According to an interview with Staff 3 (S3), R1 can do activities of daily living (ADLs) without assistance and is very verbal regarding R1's care. If staff were to touch R1's shirt or offer assistance, R1 would get agitated or mad. R1 prefers to be independent. Staff respect that wish and offer stand by assist and just watch or follow R1.

According to an interview with Staff 4 (S4), S4 helps R1 by walking R1 to the restroom and reports that R1 uses the restroom alone at night. R1 prefers to go alone. S4 reported that R1 is the most attended to client in the home. S4 says there is always staff telling R1 to walk slowly, sitting next to R1, or watching and reminding R1 so R1 does not trip or fall.

Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 1, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5