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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701118
Report Date: 08/29/2025
Date Signed: 08/29/2025 03:55:27 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
08/27/2025 and conducted by Evaluator Liza King
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250827101235
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 4FACILITY NUMBER:
392701118
ADMINISTRATOR:KOAYEN, TANNEHFACILITY TYPE:
735
ADDRESS:4011 OAK VALLEY RDTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:4CENSUS: DATE:
08/29/2025
ANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tanneh Koayen TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not ensure expired/old food was disposed of
Staff did not ensure there was food of quantity to meet the needs of the residents
INVESTIGATION FINDINGS:
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On this date, a meeting was conducted via Microsoft Teams to address observations made at the facility during a Valley Mountain Regional Center visit. Members present included Liza King, Licensing Program Manager, VMRC representatives Brian Bennett, Katina Richison, Elizabeth Toscano, Shannon Hernandez, Licensee Moses Walters SR, Tarloh Walters, Tanneh Koayen and Program Administrator Joseph Nimene.

During this discussion Administrator Tanneh Koayen acknowledged that fresh fruit and vegtables and other types of food were not of quantity or quality to meet the needs of the clients in care.

As a result of this investigation, this LPM finds the allegation to be SUBSTANTIATED-A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code.
Exit interview was conducted, a copy of this report and appeal rights were emailed to Tanneh Koayen- please sign and return to Liza.King@dss.ca.gov
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
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-20250827101235
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: WALTERS RESIDENTIAL HOME CARE 4
FACILITY NUMBER: 392701118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
CCR
85076
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85076(d)(1) Food Service
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Food has been purchased. A menu which shows resident preferences will be provided by 090225
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This was not met as evideced by the Administror acknowledged there was not suffiecient food in vaeriety and expired foods were present.
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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: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
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