392701580-5-8-2026-27-AS-LKIG-DTZT2G-20260512142042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701580
Report Date: 05/04/2026
Date Signed: 05/08/2026 11:38:57 AM

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
12/09/2025 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20251209113010

FACILITY NAME:	MANTECA ASSISTED LIVING		FACILITY NUMBER:	392701580
ADMINISTRATOR:	PARRA, EDGAR		FACILITY TYPE:	740
ADDRESS:	1130 EMPIRE AVE		TELEPHONE:	(209) 239-4531
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	130	CENSUS: 89	DATE:	05/04/2026
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Edgar Parra		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not assisting resident with medical needs

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 05/04/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Edgar Parra, who was briefly interviewed at this time.
Current census was 89 residents.
The purpose of this visit was to deliver the findings from this complaint investigation to this facility, and it's representative, in regards to the above allegation at this time.
Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that R1 moved into this facility back in June of 2025. Upon admission, it was learned that R1 had sustained a fall prior to admission and had underwent a medical procedure to address issues with R1's hip. It was learned that this contributed to complications for mobility and made R1 a designated fall risk upon admission to this facility.
Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that R1 was diagnosed with dementia requiring the use of hearing aids, wheelchair, and a walker at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

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-20251209113010

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: MANTECA ASSISTED LIVING	FACILITY NUMBER: 392701580
	VISIT DATE: 05/04/2026

NARRATIVE

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It was learned that R1 had a tendency to contact 911 since R1 had a personal cell phone which R1 kept on his/her person. It was learned that most of these calls were made when R1 felt a surge of pain or felt anxious about any physical concerns. It was learned that R1 sought out 911 for medical attention but would refuse to go to the emergency room once the paramedics arrived to transport R1 to the local hospital.
Based on a review of the forms and documents gathered during the course of this investigation, it was noted that R1 was sent out to the local hospital for a total of (2) times only from the start of August 2025 until December of 2025. It was learned that R1 returned the same day back to this facility. On one hospital visit dated on back in October 2025, R1 returned back to this facility without any new orders or changes made to R1's medical or physical care requirements. On another hospital visit after 911 was called, R1 returned back to this facility on the same day in December 2025 with a new prescription due to loose stool and diarrhea. There weren't any new changes or additional physical care needs addressed or warranted at that time.
Based on interviews conducted during the course of this investigation, it was learned that R1 was often times confused and anxious about the pain that R1 was experiencing with R1's knees. It was learned that this led R1 to act out in frustration due to the chronic pain that R1 was suffering from and R1 would often times take it out on R1's spouse and facility staff when they attempted to intervene.
It was learned that R1's care plan was completed upon admission to this facility to address these issues which the facility staff were made aware and were trained on how to de-escalate and redirect when R1 got into these bouts of frustration and lashing out. It was learned that R1 did not have any contracted services for care through a home health agency, hospice, or wound care at this time.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

LIC9099 (FAS) - (06/04)

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