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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700603
Report Date: 04/03/2025
Date Signed: 04/18/2025 02:03:59 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
10/23/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241023154318
FACILITY NAME:AUSTIN ROAD HOMEFACILITY NUMBER:
392700603
ADMINISTRATOR:SHERRY PERRY-HYLTONFACILITY TYPE:
735
ADDRESS:16590 S AUSTIN RDTELEPHONE:
(209) 823-6061
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:6CENSUS: 3DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melinda WombleTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 04/03/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Melinda Womble, who was briefly interviewed at this time.
Current census was 3 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility, and its representative, at this time.
Based on interviews conducted during the course of this investigation, this facility was found to be deficient as evidenced that a former staff person, S1, was aware that R1 had fallen and even witnessed the resident hitting their head on 06/09/24. According to an interview with S1, S1 believed that the resident should have been seen by a licensed medical professional immediately after this fall took place. Based on interviews with several staff members, R1 started to change gradually in R1’s condition after sustaining this fall, had become noncompliant with staff, unable to walk, and had difficulties performing their Activities of Daily Living (ADLs).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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
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
10/23/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241023154318

FACILITY NAME:AUSTIN ROAD HOMEFACILITY NUMBER:
392700603
ADMINISTRATOR:SHERRY PERRY-HYLTONFACILITY TYPE:
735
ADDRESS:16590 S AUSTIN RDTELEPHONE:
(209) 823-6061
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:6CENSUS: 3DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melinda WombleTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not notify authorized representative on incident

Client sustained unexplained head injury while in care
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 04/03/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Melinda Womble, who was briefly interviewed at this time.
Current census was 3 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility, and its representative, at this time.
Based on interviews conducted and a review of the forms and documents, it was learned that this facility, and it's staff members, did attempt to make contact to report the fall which took place on 06/09/2024 to the family and responsible parties of R1. It was learned that there were issues involved in getting through to the contact numbers for the family members and responsible parties at that time. It was learned that facility staff were unable to leave any voice messages detailing the nature of the call and the incident of the fall involving R1 at that time. It was learned that this facility did not have a contact number for one of the family members so an attempt to contact them was unable to be performed at that time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20241023154318
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: AUSTIN ROAD HOME
FACILITY NUMBER: 392700603
VISIT DATE: 04/03/2025
NARRATIVE
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Based on a review of the forms and documents related to R1, it was learned that R1 did not require one on one assistance and was documented as being independent. It was learned that R1 was able to ambulate normally and that there weren't any concerns with R1's ability to ambulate at that time.
Based on further interviews, it was learned that on 06/09/2024, R1 fell during the night shift at about 2116 hours. It was learned that former staff person, S1, was present and witnessed R1 fall.
It was learned that S1 admitted to being in the hallway to observe R1 and saw R1 fall. It was learned that R1 did not require any staff persons to be present in the restroom with R1, nor did facility staff assist R1 more than normal during this time frame.
It was learned that R1 did not have any prior falls that caused any injuries, but that R1 had displayed behaviors of being noncompliant and would slide to the floor. It was learned that facility staff persons would observe this behavior from R1 and report them immediately.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241023154318
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: AUSTIN ROAD HOME
FACILITY NUMBER: 392700603
VISIT DATE: 04/03/2025
NARRATIVE
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Based on a review of the forms and documents gathered during the course of this investigation, it was learned that the facility nurse (S2) assessed R1 on 06/10/24, was unable to fully diagnose R1 and was unable to determine the severity of R1’s injury due to R1 being nonverbal. The facility nurse, S2, was unable to determine if R1 had suffered a possible concussion or was experiencing any type of pain at that time.
It was learned that R1 was not taken into the hospital for an evaluation until 06/11/2024. It was learned that R1 had suffered injuries similar to someone who had been involved in a car accident as diagnosed from Doctors Hospital of Manteca licensed medical professionals. It was learned that staff failed to recognize the severity of R1’s fall and head injury despite witnessing R1’s fall and the changes to R1’s behavior. It was learned that facility staff did not take the necessary measures to have R1 properly medically evaluated and assessed to address any possible trauma/injuries from the fall in a timely manner.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.
This incident is currently under review and a future civil penalty may apply based on H&S Code 1548. Failure to correct the deficiencies may also result in civil penalties.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241023154318
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: AUSTIN ROAD HOME
FACILITY NUMBER: 392700603
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
Section Cited
CCR
85075.4(a)(c)
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The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.
The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's
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The facility designated Administrator stated that all facility staff will be trained, for no less than (1) hour in duration, on the topic of proper observation of the resident and seeking timely medical attention to address physical and mental changes unto the residents.
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physician and authorized representative, if any.
This facility was found to be deficient as evidenced by not seeking medical attention to resident who fell and hit their head until 2 days later posing an immediate threat to the Health, Safety, and Personal Rights of residents in care.
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A statement of correction, along with proof of training, will be completed and submitted into CCL by the due date.
Proof of correction will contain the name of the trainer, topics of training, and a list of attendees.
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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: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5