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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700233
Report Date: 08/20/2026
Date Signed: 08/20/2026 03:36:27 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
08/18/2026 and conducted by Evaluator Noel Wolf Petersen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260818152941
FACILITY NAME:DAVIS GUEST HOME #8FACILITY NUMBER:
502700233
ADMINISTRATOR:THOMAS, ARIELFACILITY TYPE:
740
ADDRESS:5348 KIERNAN AVENUETELEPHONE:
(209) 622-2042
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 79DATE:
08/20/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ariel ThomasTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff issued an eviction notice to the resident without providing a proper explanation
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst, LPA Noel wolf petersen, arrived unannounced to the facility to conduct complaint investigation. The LPA met with the administrator, Ariel Thomas to explain purpouse of vist.

Record review of the recent eviction notices served. 1 of 1 notices served in the last three months has a date issued, a reasoning for the notice, and some specific reasonings of house rule 3, 5, and 13 not being followed. LPA notes there is not a signature from either the client or the conservator on the notice itself. Record review of The eviction reasonings have references in the the hygenine logs, and some personal anacdotes about langauge used against staff and peers and requireing exessive prompting to go to meal times in the progress notes. Interview with R1, reported that she was not served written notice at all and did not recive the reasoning or evidence specifically.

Based on LPAs interviews which were conducted 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,are being cited on the attached LIC 9099D. A copy of the report and appeal rights were left with the adminsitrator, exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
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 2
Control Number 27-AS-20260818152941
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: DAVIS GUEST HOME #8
FACILITY NUMBER: 502700233
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87224(a)(5)
1
2
3
4
5
6
7
87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)Change of use of the facility.
1
2
3
4
5
6
7
LPA is reccomending the administrator read and send back a signed copy of 87224
Eviction Procedures. Reissue of the notice to evict was served 8/20/2026 in front of the LPA to the resident at 330.
8
9
10
11
12
13
14
Not following this requirement is evidenced by: record review of the eviction notice not being signed by resident, interviews gave a concensus statement of the resident r1 not being provided with the writen notice of eviction which contained the reasoning and evidence. not following this requirement posed a risk to the personal rights of residents 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.
SUPERVISOR'S NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2