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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700640
Report Date: 08/12/2025
Date Signed: 08/12/2025 02:42:33 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
06/16/2025 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250616092736
FACILITY NAME:COURTYARD AT RIO LAS PALMAS, THEFACILITY NUMBER:
392700640
ADMINISTRATOR:GUERRERO, LIZETHFACILITY TYPE:
740
ADDRESS:877 EAST MARCH LANETELEPHONE:
(209) 957-4711
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:80CENSUS: 58DATE:
08/12/2025
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:L. GuerreroTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are charging resident for a higher level of care than what is received
Facility staff do not ensure annual health assessments are conducted for residents in care
Facility staff falsified residents records
INVESTIGATION FINDINGS:
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The findings have been amended based on new information.

Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to open a complaint investigation into the above listed allegations.

Allegation: Staff are charging resident for a higher level of care than what is received.

Based on records reviewed and interviews conducted the facility is not following their approved plan of operation. The facility's plan of operation submitted to the department has been amended to include a new level of care description and fees. The facility has implemented this new level of care descriptions and fees without submitting to the licensing agency for approval prior to implementation.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
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 4
Control Number 27-AS-20250616092736
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: COURTYARD AT RIO LAS PALMAS, THE
FACILITY NUMBER: 392700640
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/22/2025
Section Cited
CCR
87208(a)(1-3)
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(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(1) Statement of purposes and program goals.
(2) A copy of the Admission Agreement, containing basic and optional services.(3) Statement of admission policies and procedures regarding acceptance of persons for services.
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Licensee will ensure an updated plan of operation be submitted to LPA by POC due date to include, but not be limited to: Amending the current admission agreement and care conference plan to include a new level of care description and fees. The new forms should be signed by all responsible party or individuals.
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This requirement is not met as evidenced by information reviewed and interviews conducted.
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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: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250616092736
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: COURTYARD AT RIO LAS PALMAS, THE
FACILITY NUMBER: 392700640
VISIT DATE: 08/12/2025
NARRATIVE
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Allegation: Facility staff do not ensure annual health assessments are conducted for residents in care. Based on interviews with the alleged primary care physician and review of documentation presented the facility used information from a falsified physician's report to determine the level of care needed to meet R1's needs. The assessments completed was based on the original physician's report dated 7/7/2022. The next physician's report is dated 10/1/2024 the signature and length of time resident has been your patient is different from the original. The lengths of time vary on both reports the first is 6/22 to present and the second is 6/23 to present. The PCP was contacted by the department and was told that the encounters for R1 were for June of 2022 and July of 2022. No other encounters were confirmed by the Physician in question.

Allegation: Facility staff falsified residents records. The assessments completed was based on the original physician's report dated 7/7/2022. The next physician's report is dated 10/1/2024 the signature and length of time resident has been your patient is different from the original. The lengths of time vary on both reports the first is 6/22 to present and the second is 6/23 to present. The PCP was contacted by the department and was told that the encounters for R1 were for June of 2022 and July of 2022. No other encounters were confirmed by the Physician in question. The office of the Physician in question denied seeing or billing R1 for services since July of 2022. Therefore the other Physician's reports are questionable to the authenticity of the signatures and the information it contains about R1.











Based on records reviewed and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22 are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report was given
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250616092736
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: COURTYARD AT RIO LAS PALMAS, THE
FACILITY NUMBER: 392700640
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/13/2025
Section Cited
CCR
87463(a)
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87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.
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Licensee agrees to submit plan to be in compliance with this regulation to LPA by POC due date of 8/13/2025
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This requirement is not met as evidenced by review of documentation presented the facility used information from a falsified physician's report to determine the level of care needed to meet R1's needs. The assessments completed was based on the original physician's report dated 7/7/2022. The next physician's report is dated 10/1/2024 the signature and length of time resident has been your patient is different from the original.
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Deficiency Dismissed
Type A
08/13/2025
Section Cited
HSC
1569.50(a)(3)
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(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
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Licensee agrees to submit plan to be in compliance with this regulation to LPA by POC due date of 8/13/2025
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This requirement was not met as evidenced by interviews, the facility jeopardized the health, safety, and well-being of the resident in care by utilizing false information to assess and charge for services. This posed an immediate health risk to the resident 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: Albert Johnson
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: 4 of 4