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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005824
Report Date: 08/15/2025
Date Signed: 08/15/2025 09:49:52 AM

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
04/15/2025 and conducted by Evaluator Noel Wolf Petersen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250415154201
FACILITY NAME:LINDEN GROVE ADULT RESIDENTIALFACILITY NUMBER:
397005824
ADMINISTRATOR:CAMPBELL, MARICA Z.FACILITY TYPE:
735
ADDRESS:21373 EASTERN HEIGHTS RDTELEPHONE:
(209) 430-8869
CITY:LINDENSTATE: CAZIP CODE:
95236
CAPACITY:6CENSUS: 5DATE:
08/15/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Renee HaneyTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Personal Rights violation - Facility failed to report to conservator medical appointments by psychiatrist
INVESTIGATION FINDINGS:
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On 8/15/2025 at 9:15 Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unannounced to deliver findings related to a complaint investigation, the LPA met with Renee Haney to explain the purpose of the visit. It was alleged that the facility failed to inform the relatives and authorized representative to activities related to care and prescribing medication.

The allegation was investigated by record review and interview. The facility provided a statement that denies the physician had a role in providing any kind of care, and instead was assessing the resident to stay in the facility. In conflict with that statement, LPA observed from the facility documentation (Emergency Contact form and MARs) that listed the physician as the care provider on those forms. The authorized representative provided a statement that denies being informed of the type of care being provided or the physicians role in providing the care.

Continued on C. Page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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-20250415154201
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: LINDEN GROVE ADULT RESIDENTIAL
FACILITY NUMBER: 397005824
VISIT DATE: 08/15/2025
NARRATIVE
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In support of that statement, no mention of the physician is made in a record review of emails to the authorized representative provided by the facility, or annual and quarterly reports by a relevant third party(VMRC) where other physicians are mentioned by name and role. The LPA notes that the signature on the Emergency Contact documentation designating the role of the physician appears not to be the signature of the authorized representative.

Based on LPAs observations and interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6 85072 (b)(2)), is being cited on the attached LIC 9099D.

A copy of the appeal rights were provided, a exit interview was conducted and a copy of the report was left with the staff.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250415154201
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: LINDEN GROVE ADULT RESIDENTIAL
FACILITY NUMBER: 397005824
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/18/2025
Section Cited
CCR
85072(b)(2)
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85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights. (2) To have the facility inform his/her relatives and authorized representative, if any, of activities related to his/her care and supervision, including but not limited to notification of any
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Licensee read and sign an adknowlement of 85072, email a copy to the LPA by the POC date.
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 modifications to the needs and services plan. This requirement was not met as evidenced by: record review detailing a undisclosed phycisian was also a perscribing phycisian.
which poses a threat to the personal rights of the 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: 08/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3