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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397203015
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:17:06 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
03/10/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250310153315
FACILITY NAME:CREEKSIDE GUEST HOMEFACILITY NUMBER:
397203015
ADMINISTRATOR:SHERON N. L. WOOFACILITY TYPE:
735
ADDRESS:3019 FAIRBURY LANETELEPHONE:
(209) 298-2267
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 4DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dolpha BomarTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not report incident per regulatory requirements
INVESTIGATION FINDINGS:
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On 5/22/2025 at 1:30pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to deliver findings for the allegation noted above. LPAs met with Licensee Dolpha Bomar and explained the purpose of the visit. During this investigation, LPA conducted interviews with three staff members and two clients in care. Additionally, LPA reviewed facility care notes for March 2025. Based on interviews conducted and record reviews, it was revealed that on 3-8-2025, resident1 (R1) and R2 engaged in a physical altercation resulting in R1 sustaining minor injuries and requiring first aid and urgent care attention. Interviews further revealed that although incident was reported to licensing department, it was not reported to ombudsman and police per regulatory requirements. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citation is issued under Title 22, Division 6, and noted on LIC 9099D. An exit interview was conducted with Licensee and a copy of this report was provided. Appeal rights and LIC 811 provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 4
Control Number 27-AS-20250310153315
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: CREEKSIDE GUEST HOME
FACILITY NUMBER: 397203015
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2025
Section Cited
CCR
80061(d)
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80061 Reporting Requirements. (d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not messed as evidenced by:
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Licensee to ensure staff training on mandated reporting and Section 80061 reporting requirements to be completed by POC due date. Licensee to utilize an outside vendor for training and send proof of completed training to LPA by POC date.
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Based on interview, Licensee did not ensure the reporting of an incident of resident-to-resident abuse to ombudsman and local law enforcement. This posed a potential health and safety risk to residents 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: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
03/10/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250310153315

FACILITY NAME:CREEKSIDE GUEST HOMEFACILITY NUMBER:
397203015
ADMINISTRATOR:SHERON N. L. WOOFACILITY TYPE:
735
ADDRESS:3019 FAIRBURY LANETELEPHONE:
(209) 298-2267
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 4DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dolpha BomarTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulting in client injuries
Facility did not seek timely medical care for client's injures.
INVESTIGATION FINDINGS:
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On 5/22/2025 at 1:30pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to deliver findings for the allegation noted above. LPAs met with Licensee Dolpha Bomar and explained the purpose of the visit. During this investigation, LPA conducted interviews with three staff members and two clients in care. Additionally, LPA reviewed facility care notes for March 2025, individual program plans (IPPs), staffing schedule, and physician’s reports.
Allegation: Neglect/Lack of Supervision resulting in client injuries. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews conducted, it was revealed that on 3-8-2025, resident1 (R1) and R2 engaged in a physical altercation resulting in R1 sustaining minor injuries and requiring first aid and urgent care attention. Interviews and record reviews further revealed that two staff members were on duty and engaging in on-going attempts to separate R1 and R2 during the altercation. It was further revealed that Administrator and Licensee were notified of the incident by staff on duty. Staffing schedule reviewed revealed that facility consistently ensures at least two staff on duty during AM and PM shifts. {Cont. on LIC 9099C}

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250310153315
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: CREEKSIDE GUEST HOME
FACILITY NUMBER: 397203015
VISIT DATE: 05/22/2025
NARRATIVE
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 As a result, although R1 sustained minor injuries due to a physical altercation, there is not a preponderance of evidence to conclude a lack of supervision or neglect of residents in care, therefore, this allegation is UNSUBSTANTIATED.

Allegation: Facility did not seek timely medical care for client’s injuries. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews conducted, it was revealed that on 3-8-2025, resident1 (R1) and R2 engaged in a physical altercation resulting in R1 sustaining minor injuries and requiring first aid and urgent care attention. Interviews and record reviews revealed R1 sustained minor injuries as a result of the altercation and required first aid and urgent care attention. Interviews conducted further revealed that on 3-8-25, staff on duty applied first aid techniques to R1 and Administrator transported R1 to urgent care for further evaluation. Interviews also revealed that R1 refused urgent care services upon arrival and was transported back to the facility by Administrator with instructions to staff for additional monitoring. As a result, there is not a preponderance of evidence to conclude facility did not perform timely medical care for client’s injuries, 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 Licensee and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4