392701118-1-22-2026-27-AS-LKIG-DQXMLL-20260203084231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701118
Report Date: 01/22/2026
Date Signed: 01/22/2026 03:16:57 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
12/05/2025 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20251205113539

FACILITY NAME:	WALTERS RESIDENTIAL HOME CARE 4		FACILITY NUMBER:	392701118
ADMINISTRATOR:	KOAYEN, TANNEH		FACILITY TYPE:	735
ADDRESS:	4011 OAK VALLEY RD		TELEPHONE:	(510) 688-3552
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY:	4	CENSUS: 3	DATE:	01/22/2026
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Tanneh Koayen		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff hit client in care
Staff caused injury to client in care

INVESTIGATION FINDINGS:

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On 1-22-2026 at 2:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Tanneh Koayen and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members and three clients in care. LPA also reviewed facility file documentation including incident reports, physician’s report, behavior intervention plan, individual program plan (IPP), behavior tracking notes, body check verification form, abuse reporting form, police report, photograph, and client notes all pertaining to resident1 (R1).

Allegation: Staff hit client in care. LPA conducted interviews and record reviews as noted above. This allegation states that a staff member hit a client in care on or about 11-26-2025. Further investigation revealed that a police report was generated on 11-20-2025 based off an incident in which R1 reported “battery.” Police conducted an interview with R1 on 11-20-2025 while R1 was in the hospital.

{Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

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-20251205113539

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
	VISIT DATE: 01/22/2026

NARRATIVE

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Interviews and record reviews further revealed that R1 was engaged in a resident-to-resident altercation on 11-18-2025 with a bruise noted by staff on 11-19-2025, and a hospitalization on 11-20-2025 after R1 called an ambulance for service. Interviews conducted confirmed the resident-to-resident altercation but did not reveal corroborated statements or witnessing of a staff member hitting R1.
An incident report dated 11-28-2025 revealed R1 called an ambulance service due to “not feeling well” and was diagnosed with gastroenteritis and discharged back to facility with no further incidents. Further documentation review revealed R1 has a history of frequent calls to 911 and other behavior attention activities. Based on interviews and record reviews, although the allegation of a staff member hitting a client exists, there is not a preponderance of evidence to conclude the event occurred. As a result, this allegation is UNSUBSTANTIATED.

Allegation: Staff caused injury to client. LPA conducted interviews and record reviews as noted above. This allegation states that a staff member caused an injury to a client in care on or about 11-26-2025 due to hitting the client. Further investigation revealed that a police report was generated on 11-20-2025 based off an incident in which R1 reported “battery.” Police conducted an interview with R1 on 11-20-2025 while R1 was in the hospital. Interviews and record reviews further revealed that R1 was engaged in a resident-to-resident altercation on 11-18-2025 with a bruise noted by staff on 11-19-2025, and a hospitalization on 11-20-2025 after R1 called an ambulance for service. Interviews conducted confirmed the resident-to-resident altercation but did not reveal corroborated statements or witnessing of a staff member causing an injury to R1. A photograph taken 12-5-2025 revealed a small circular wound on R1 left upper arm which was light in color. Interviews conducted did not reveal the exact cause of the bruise.
An incident report dated 11-28-2025 revealed R1 called an ambulance service due to “not feeling well” and was diagnosed with gastroenteritis and discharged back to facility with no further incidents. Further documentation review revealed R1 has a history of frequent calls to 911 and other behavior attention activities. Based on interviews and record reviews, although the allegation of a staff member causing an injury to client in care exists, there is not a preponderance of evidence to conclude the event occurred. As a result, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred
An exit interview was conducted with Administrator, and a copy of this report was provided. Appeal right provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

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