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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701318
Report Date: 04/02/2025
Date Signed: 04/02/2025 03:56:06 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
01/16/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250116080733
FACILITY NAME:ESTEEMED RESIDENTIAL CARE 2FACILITY NUMBER:
392701318
ADMINISTRATOR:WALTERS, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:2431 ETCHEVERRY DRIVETELEPHONE:
(925) 219-2787
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:4CENSUS: 5DATE:
04/02/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Christopher WaltersTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility staff did not report incident to licensing department
INVESTIGATION FINDINGS:
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On 4-2-25 at 2:15pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to deliver and discuss findings for the allegation noted above. LPA met with Administrator Christopher Walters and explained the purpose of the visit. During this investigation, LPA conducted interviews with three staff members and one resident. LPA also reviewed facility file documentation including staff training records, physician’s report for resident1 (R1), care notes for R1, individual program plan (IPP) for R1, and photographs pertaining to allegation.
Based on interviews and record reviews, it was determined that on 1-8-25, R1 engaged in a behavior episode involving self injurious behavior, attempting to hit staff, and property destruction which prompted staff members on duty to perform a manual restraint involving the escorting of R1 to his bed. This manual restraint consisted of staff grabbing upper arms of R1 on both sides. Interviews conducted revealed manual restrain was used due to risk of self injury and injury to staff during this behavior episode.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
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
Control Number 27-AS-20250116080733
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: ESTEEMED RESIDENTIAL CARE 2
FACILITY NUMBER: 392701318
VISIT DATE: 04/02/2025
NARRATIVE
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Upon further record review and interview, it was determined that the above incident was not reported to licensing department per regulatory requirements. As a result, this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided to. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250116080733
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: ESTEEMED RESIDENTIAL CARE 2
FACILITY NUMBER: 392701318
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
85161(b)
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85161(b) Emergency Intervention Documentation and Reporting Requirements (b) Each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day. This time frame shall supersede the reporting time frame required by Section 80061(b). This requirement was not met as evidenced by:
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Licensee to ensure to ensure completed staff training on reporting requirements including use of manual restraints. Licensee to complete training with staff using an outside vendor. Proof of completed training to be sent to LPA by POC due date.

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Based on interview and record, an incident in which R1 was manually restrained due to behaviors was not reported to Licensing department per regulations. This posed a potential health and safety risk to resident in care.
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Licensee to read regulation 85161 and submit a signed declaration of understanding to LPA by POC due date.
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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: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
01/16/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250116080733

FACILITY NAME:ESTEEMED RESIDENTIAL CARE 2FACILITY NUMBER:
392701318
ADMINISTRATOR:WALTERS, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:2431 ETCHEVERRY DRIVETELEPHONE:
(925) 219-2787
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:4CENSUS: 4DATE:
04/02/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Christopher WaltersTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Resident sustained bruising while in care due to inappropriate interventions by facility staff
INVESTIGATION FINDINGS:
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On 4-2-2025 at 2:15pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to deliver and discuss findings for the allegation noted above. LPA met with Administrator Christopher Walters and explained the purpose of the visit. During this investigation, LPA conducted interviews with three staff members and one resident. LPA also reviewed facility file documentation including staff training records, physician’s report for resident1 (R1), care notes for R1, individual program plan (IPP) for R1, and photographs pertaining to allegation.
Based on interviews and record reviews, it was determined that on 1-8-25, R1 engaged in a behavior episode involving self injurious behavior, attempting to hit staff, and property destruction which prompted staff members on duty to perform a manual restraint involving the escorting of R1 to his bed. This manual restraint consisted of staff grabbing upper arms of R1 on both sides.

{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250116080733
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: ESTEEMED RESIDENTIAL CARE 2
FACILITY NUMBER: 392701318
VISIT DATE: 04/02/2025
NARRATIVE
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Interviews conducted revealed manual restraint was used due to risk of self injury and injury to staff during this behavior episode. Record reviews and interviews further revealed that on 1-9-25, facility staff notified day program of the 1-8-25 incident and stated first aid was applied to R1’s face, with R1 returning to facility on 1-9-25 from day program with no additional visual marks. On 1-13-25, care notes and interviews revealed that facility staff was notified from day program of a concern regarding a visual bruise on R1’s left side near R1’s rib cage. Care notes and interviews further revealed first aid was applied to this bruise.
Based on interviews and records reviews regarding this investigation, it is determined that although R1 sustained a bruise noted on 1-13-25, it is undetermined if bruise occurred as a result of the manual restraint used on 1-8-25. As a result, the above 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 rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5