<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455920100
Report Date: 08/22/2025
Date Signed: 08/22/2025 06:25:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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 Kayla Adkison
COMPLAINT CONTROL NUMBER: 59-AS-20250415113706
FACILITY NAME:SAPPHIRE RESIDENTIALFACILITY NUMBER:
455920100
ADMINISTRATOR:LEAK, RANDYFACILITY TYPE:
735
ADDRESS:1208 COGGINS STREETTELEPHONE:
(530) 200-0701
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 3DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Phoenix Gutierrez, Direct Service ProviderTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision resulting in an altercation between residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On August 22, 2025, Licensing Program Analyst (LPA), Kayla Adkison, arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted at the door by Phoenix Gutierrez, Direct Service Provider, and explained the purpose of the visit. LPA further spoke with Administrator, Crystal Monismith, via telephone and explained the purpose of the visit. Administrator provided verbal approval for staff to sign for this report. During the visit, two (2) clients and three (3) staff were present in the facility.

Allegation - Staff did not provide adequate supervision resulting in an altercation between residents.

It was alleged that on April 15, 2025, two clients were observed in a loud, verbal fight in the street in front of the facility. LPA Adkison received video surveillance footage of two residents in front of the facility yelling obscenities and “challenging” each other to a fight. One individual then returns inside the facility and the other turns and proceeds to walk down the street away from the facility. During the course of the video, there is no sign of any staff member outside with the clients attempting to redirect or supervise the situation.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
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 3
Control Number 59-AS-20250415113706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAPPHIRE RESIDENTIAL
FACILITY NUMBER: 455920100
VISIT DATE: 08/22/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the investigation, interviews with staff were conducted. Staff members indicated that the two clients involved in the altercation “sometimes disagree and it can get heated.” At the time of the fight, it was discovered one (1) staff member was present in the facility for three (3) clients. Staff admitted that nobody went outside with the two fighting clients as they could not leave the remaining resident in the facility alone. Staff claimed they observed the altercation from inside the facility to make sure the clients did not get hurt. Staff further admitted clients have been outside the facility yelling or causing general disturbances in the neighborhood. Staff members stated sometimes clients need to “take a breather” and they are allowed to take a walk and deal with their frustrations on their own. Staff claimed they will attempt to redirect clients when these moments happen.

Witness interviews were also conducted. Multiple witnesses stated there have been several instances where clients have been outside the facility without supervision yelling profanities and causing disturbances. Witnesses indicated they did not feel safe and were also concerned for the safety of the residents without any direct supervision during what appeared to be behavioral outbursts. During record review, LPA noted two (2) of three (3) residents are medically cleared to leave the facility without staff supervision. Both clients involved in the altercation observed in the video footage were confirmed to be able to leave the facility unassisted.

Based on observation, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC 9099-D. Exit interview conducted and a copy of this report was provided to Crystal Monismith, Administrator, via email.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250415113706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAPPHIRE RESIDENTIAL
FACILITY NUMBER: 455920100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
1
2
3
4
5
6
7
Licensee shall submit a letter of understanding of this regulation and shall draft a plan on how staff will deal with a similar situation between clients in the future by end of business on September 5, 2025.
8
9
10
11
12
13
14
Based on observation, interviews, and record review, the licensee did not comply with the section cited above as residents were involved in a verbal altercation without any supervision or attempted redirection which poses a potential health, safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3