392701576-7-7-2026-27-AS-LKIG-DW6TYY-20260720150931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701576
Report Date: 07/07/2026
Date Signed: 07/07/2026 03:33:42 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
05/19/2026 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20260519094937

FACILITY NAME:	CRYSTAL CREEK SENIOR LIVING		FACILITY NUMBER:	392701576
ADMINISTRATOR:	ANGELA RINGU		FACILITY TYPE:	740
ADDRESS:	2435 WAGNER HEIGHTS ROAD		TELEPHONE:	(209) 477-5353
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	80	CENSUS: 72	DATE:	07/07/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Angela Ringu		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not prevent residents from engaging in inappropriate sexual behaviors
Staff are not checking on residents regularly
Staff are not following acceptance and retention limitations procedures
Staff are not meeting residents needs
Staff failed to observe changes in resident

INVESTIGATION FINDINGS:

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On 7-7-2026 at 11:00am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation, deliver and discuss findings for the allegations noted above. LPA met with Administrator Angela Ringu and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members and seven residents in care. LPA also reviewed facility file documentation including care notes, observation notes for various residents in care, needs and service plan, and physician’s reports pertaining to resident1 (R1) and R2. LPA also reviewed additional documentation including incident reports, death report, death certificate and activities calendar. LPA also conducted a facility observation as part of this investigation.

Allegation: Staff did not prevent residents from engaging in inappropriate sexual behaviors. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews it was revealed that R2 has engaged in sexual relationships with at least one resident in care. Although these events occurred, it was further revealed that these encounters were consensual. {Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

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-20260519094937

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: CRYSTAL CREEK SENIOR LIVING	FACILITY NUMBER: 392701576
	VISIT DATE: 07/07/2026

NARRATIVE

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Additionally, care notes reviewed revealed multiple attempts by staff to redirect these encounters for purposes of promoting safety, privacy, and resident rights. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff are not checking on residents regularly. LPA conducted interviews, record reviews, and observation as noted above. Based on the evidence reviewed, it was revealed that staff conduct regular rounds for residents in care to ensure safety. Additionally, record reviews and interviews revealed that various residents require frequent checks, which were observed and noted on needs and services plans and observation notes. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff are not following acceptance and retention procedures. LPA conducted interviews and record reviews as noted above. Based on evidence reviewed, it was revealed that facility currently provides care for multiple residents under the age of 60. It was further revealed that facility has adequately been able to meet the needs of these residents including physical, social, and mental health needs. LPA observed activities and care provided to identified residents under the age of 60. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff are not meeting resident needs. LPA conducted interviews and record reviews as noted above. This allegation stated that resident1 (R1) was found with a leg laceration on 5-5-2026 without proper treatment applied. Based on interviews and record reviews, it was revealed that R1 experienced a leg laceration which staff attended to via first aid. Additionally, it was revealed that staff called 911 personnel who attended to the laceration and transported R1 to the hospital. On 5-6-2026, it was revealed that R1 passed away at the hospital. Additional care notes reviewed indicate staff’s involvement in care planning including appointments and communication with dialysis center for R1. Additional notes indicate staff’s attempts to redirect R1 to his special diet and informing R1’s physician regarding R1’s refusal to comply with diet restrictions. Additionally, LPA observed staff meeting the general needs of residents in care. As a result, there is not a preponderance of evidence to conclude staff are not meeting resident needs, therefore, this allegation is UNSUBSTANTIATED.

{Cont. on 9099C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260519094937

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: CRYSTAL CREEK SENIOR LIVING	FACILITY NUMBER: 392701576
	VISIT DATE: 07/07/2026

NARRATIVE

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Allegation: Staff failed to observe changes in resident. LPA conducted interviews and record reviews as noted above. This allegation states that R1 was found deceased in facility after experiencing an injury. Based on evidence reviewed including interviews and record reviews, it was revealed that on 5-5-2026, R1 experienced a leg laceration which was tended to by facility staff. R1 was then sent to a local hospital for additional treatment. On 5-6-2026, facility staff learned that R1 passed away at the hospital with a stated cause of cardiac arrest. A review of death certificate states place of death at local hospital with immediate cause of death to be acute respiratory failure and secondary causes including cardiac arrest and end stage renal failure. Care notes reviewed indicate staff had been engaging in regular observation of R1’s diet non-compliance, behaviors, and medication. It was further revealed that facility staff have arranged for R1’s follow-up doctor appointments and required dialysis treatment. Care notes and interviews also revealed that facility staff offered consultations to R1 regarding diet restrictions. An observation conducted by LPA revealed staff observing and addressing various resident needs. As a result of the evidence reviewed, there is not a preponderance of evidence to suggest staff failed to observe changes in a resident, therefore, 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 rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

LIC9099 (FAS) - (06/04)

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