347005202-9-10-2026-27-AS-SRIN-DY6VBT-20260922161804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005202
Report Date: 09/10/2026
Date Signed: 09/10/2026 11:34:58 AM

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
03/04/2026 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20260304151756

FACILITY NAME:	ST. CHRISTOPHER MANOR		FACILITY NUMBER:	347005202
ADMINISTRATOR:	BENITEZ, NORMA		FACILITY TYPE:	740
ADDRESS:	8564 BRENTWICK WAY		TELEPHONE:	(916) 509-9819
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	4	CENSUS: 4	DATE:	09/10/2026
		UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Norma Benitec		TIME COMPLETED:	11:46 AM

ALLEGATION(S):

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Staff neglect resulted in a resident to be hospitalized
Staff did not meet a resident's incontinence needs
Staff did not timely address a resident's change in medical condition
Staff did not properly report an incident involving a resident
Staff did not seek timely medical attention for a resident

INVESTIGATION FINDINGS:

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On 09/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Licnesee Norma Benitec and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the above allegations. The current census is four. A brief interview was conducted with Licensee Benitec.

It was alleged that staff neglect resulted in a resident to be hospitalized. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. Throughout the course of the investigation, it was learned that on 02/18/2026, at approximately 10:00 a.m., R1 sustained an unwitnessed fall in R1’s bedroom. Licensee Norma Benitez informed R1 that she intended to call an ambulance; however, R1 refused. At approximately 1:30 p.m. that same day, Licensee Benitez contacted emergency medical services. Paramedics responded to the facility, but R1 refused to be evaluated or transported to the hospital.
CONTINUED LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026

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-20260304151756

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: ST. CHRISTOPHER MANOR	FACILITY NUMBER: 347005202
	VISIT DATE: 09/10/2026

NARRATIVE

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On 02/25/2026, Licensee Benitez contacted R1’s responsible party and reported that R1 was experiencing pain in the hip area where R1 had fallen. Licensee Benitez requested that the responsible party take R1 to the hospital. A follow-up medical appointment was scheduled for 02/27/2026. According to UC Davis medical records, no fractures were identified, and R1 was diagnosed with arthritis. Moreover, during another incident on 03/02/2026, R1 was admitted to UC Davis Medical Center with a blood pressure reading of 77/44. R1 was admitted to the intensive care unit and diagnosed with septic shock. According to R1’s responsible party, R1 was admitted to the intensive care unit because hospital staff were unable to stabilize R1’s blood pressure. R1 did not return to the facility following this hospitalization. Based on the records reviewed, R1 did not require special supervision but required full assistance with activities of daily living. R1 was able to ambulate and transfer independently. At the time of the fall, R1 had resided at the facility for approximately 20 days, and no prior falls had been documented. After the fall was discovered, the facility contacted emergency medical services, but R1 refused evaluation and transportation. Therefore, the Department was unable to corroborate the allegation that staff neglect resulted in a resident to be hospitalized.

It was alleged that staff did not meet a resident’s incontinence need. This investigation consisted of interviews with staff and residents, observations, and record reviews. The Licensee Benitec stated that residents receive incontinence care every three to four hours and as needed. Three of three residents interviewed confirmed that staff assist them with incontinence care, like living in the home and reported no concerns. During a facility visit on 07/10/2026 and today’s visit (09/10/2026) LPA Lee did not detect any incontinence odors. It was learned that the facility does not document when residents’ incontinence briefs are changed or when staff assist residents with toileting. However, staff reported monitoring residents every three to four hours and as needed, therefore, the Department was unable to corroborate the allegation that staff did not meet a resident’s incontinence need.

It was alleged that staff did not properly report an incident involving a resident. This investigation consisted of interviews with staff and R1’s responsible party, as well as a review of records. Administrator Benitez denied the allegation and stated that incidents involving R1 were reported to R1’s responsible party and faxed to the Department. According to coordinator notes dated 02/18/2026, R1 sustained a fall, and staff notified R1’s responsible party. Because R1 refused evaluation by paramedics, the responsible party agreed to transport R1 to the hospital that afternoon but did not arrive.

PAGE 2 CONTINUED LIC 9099-C

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260304151756

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: ST. CHRISTOPHER MANOR	FACILITY NUMBER: 347005202
	VISIT DATE: 09/10/2026

NARRATIVE

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The incident reports were faxed to the Department on 02/18/2026 at 11:57 p.m. On 03/02/2026, staff notified R1’s responsible party that R1 was coughing up yellow phlegm. X-ray results showed no fractures, only arthritis. A home health nurse evaluated R1 and noted low blood pressure. Staff requested that 911 be called; however, R1 refused. On 03/04/2026, R1’s responsible party transported R1 to the hospital. The related incident reports were faxed to the Department on 03/04/2026 at 6:44 p.m., therefore, the Department was unable to corroborate the allegation that staff failed to seek timely medical attention.

It was alleged that staff did not timely address a resident’s change in medical condition and staff did not seek timely medical attention for a resident. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. Throughout the course of the investigation, it was learned that on 02/18/2026, at approximately 10:00 a.m., R1 sustained an unwitnessed fall in their room. Licensee Benitez called paramedics at approximately 1:30 p.m.; however, R1 refused evaluation and transportation. R1 was later transported to the hospital on 02/20/2026. No injuries were identified, and R1 was discharged with a diagnosis of arthritis. On 02/27/2026, R1 spent the day with their responsible party, who reported no signs of illness. On 02/28/2026, staff observed that R1 appeared tired and went to bed after breakfast. On 03/01/2026, R1 continued to report fatigue and began producing yellow phlegm. On 03/02/2026, R1 was transported to UC Davis Medical Center with low blood pressure and was admitted to the intensive care unit with septic shock. Records and interviews showed that staff contacted paramedics after R1’s fall, but R1 refused medical care. Staff continued monitoring R1 and sought medical attention when R1’s symptoms persisted and worsened. Therefore, the Department was unable to corroborate the allegation that staff did not timely address a resident’s change in medical condition and that staff did not seek timely medical attention for a resident.

The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Licensee Benitec and the LIC 9099 report was provided to the facility at the end of the visit.

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SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026

LIC9099 (FAS) - (06/04)

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