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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392790075
Report Date: 12/18/2025
Date Signed: 12/18/2025 03:59:31 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
10/10/2025 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20251010110221
FACILITY NAME:HAYNES BOARD AND CAREFACILITY NUMBER:
392790075
ADMINISTRATOR:PARKER, CHERYLFACILITY TYPE:
735
ADDRESS:17201 N. TULLY ROADTELEPHONE:
(209) 727-5834
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:30CENSUS: 17DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Sandra Haynes Andrews AND Melissa GirardoTIME COMPLETED:
03:57 PM
ALLEGATION(S):
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facility staff does not treat clients with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced on 3:00pm, 12/18/25 to deliver findings of the investigation into the above allegation. LPA met with administrator Melissa Geriado and Licensee Sandra Haynes Andews and explained the purpose of the visit.

LPA interviewed 5 of 20 Staff, and 6 of 17 clients, and 2 Day Program Administrators and statements were made that supported the allegation with specific details. the consensus statement is that Staff S6 was unprofessional in thier treatment of the clients resulting in a risk to the personal rights of clients in care. 1 resident(R1) make the claim of S6 reffered to them as a bitch and made threats to unplug thier tv, take thier desset, and give thier desk to their neighbor if they did not attend program. 1 other resident(R2) refered to S6 as nice in general but when upset could be mean, rude, and made them generally afraid to interact with s6. 2 staff(S5 and S4) made assertions that all staff have observed instances of rudenes from S6 to the staff and but don't want to bring them up out of fear of retailiation by s6, the same 2 staff(S5 and S4) charactized s6 as nice but had intense moods where her tone was overly forceful with instruction to the clients.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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 3
Control Number 27-AS-20251010110221
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: HAYNES BOARD AND CARE
FACILITY NUMBER: 392790075
VISIT DATE: 12/18/2025
NARRATIVE
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1 Day Program Administrator commented that S6 was regularly dismissive and rude to them when calls were made on behalf of the clients.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22) is being cited on the attached LIC 9099D.

Citation was issued, appeal rights were provided, a copy of the report was read and given to the staff. exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20251010110221
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: HAYNES BOARD AND CARE
FACILITY NUMBER: 392790075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2025
Section Cited
CCR
80072(a)(1)
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80072(a)(1)80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee is going to formalize thier weekly meeting about grievences in the facility from clients and staff, LPA is asking for a signed affidavit of CCR 80072 by end of day on the POC date.
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This requirement was not met as evidenced by: interviews of residents, staff, and others where corroborating statements were made that a particular staff was inappropritely rude in thier dealings with clients.

This poses an immedate risk to the personal rights of persons in care.
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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: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3