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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 07/25/2025
Date Signed: 07/25/2025 03:03:30 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
10/15/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20241015163935
FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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1) Staff gave resident medication that was not prescribed to that resident resulting in hospitalization
2) Staff handled resident in a rough manner resulting in a broken nose
3) Staff did not allow resident to visit/contact family.
4) Staff did not allow resident to leave the facility.
5) staff verbally abused residents
6) Staff financially abused residents
7) staff left residents unsupervised
8) staff forces residents to eat even when they don't want to.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 7/25/25 at 1:15pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Lita Siebenthal and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA contacted the Reporting Party (RP) and all co complainants regarding the allegations. LPA conducted interviews with current staff members and any staff members present while at the location in Fort Bragg, CA. LPA was unable to interview the alleged victim as LPA does not know their current whereabouts and no current information was provided to LPA by A1.

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: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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 27-AS-20241015163935
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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
VISIT DATE: 07/25/2025
NARRATIVE
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LPA was unable to interview one of the alleged victims as they passed away prior to being interviewed by LPA. LPA was unable to conduct meaningful interviews with current residents as all residents currently in placement are not cognitively able to respond to interview questions. Per statements obtained from the RP, the hospital could not perform any tests that would indicate resident received a medication not prescribed for them. LPA could not interview this resident as they had passed away prior to being interviewed. Additionally, all staff interviewed denied providing any insulin or medications that would explain low blood sugar upon admission. LPA was unable to obtain any corroborating statements or documentation to support the allegation.

LPA is unable to corroborate the allegations of physical, financial or verbal abuse. LPA obtained text messages between one of the co-complainants and the licensee, LPA observed no reported concerns from the co-complainant regarding physical, verbal or financial abuse documented in the text communications between the licensee/facility staff and the co-complainant. LPA observed documentation that R2 had a fall and broken nose prior to being accepted to the facility. Per interviews with facility staff R2 had a nose bleed that could not be stopped and staff applied appropriate pressure to the site to ensure the bleeding stopped and when it was not, they transported R2 to the hospital for evaluation. All co-complainants interviewed, indicated the only evidence was statements obtained form R2 while at the dentist and hospital. Per R2's authorized representative, R2 is diagnosed with dementia and was diagnosed at the hospital with UTI. All staff members denied any abuse or witnessing abuse. LPA asked R2's authorized representative for any documentation or paperwork provided to R2 or them for selling R2's property and Authorized representative has not provided any evidence to LPA and that is not reflective of the text messages observed between facility staff and the authorized representative.

Regarding the final allegations of residents being left unsupervised, Resident not able to contact family and residents being forced to eat food when they do not want to are also unsubstantiated. LPA has not been able to obtain any evidence or statements corroborating the allegations. While one co-complainant observed some residents in the car while licensee was at the dentist with R2, they could not confirm whether there was another staff member present in the car with residents providing supervision. Staff members denied leaving any residents unsupervised. Staff members denied restricting phone conversations or contact with family members. Report continued on LIC 9099-C2.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241015163935
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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
VISIT DATE: 07/25/2025
NARRATIVE
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Again LPA was unable to obtain any evidence or corroborating statements from co-complainants or witnesses that residents are forced to eat at times when they do not want. All residents who current reside in the facility have a diagnosis of dementia and may need frequent reminders. Staff members denied the allegations and no other evidence has been obtained or provided to corroborate the allegations.

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, physical abuse) are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. 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: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3