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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700235
Report Date: 07/24/2025
Date Signed: 07/24/2025 10:42:20 AM

Unsubstantiated


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
04/24/2025 and conducted by Evaluator Ellen Lindstrom
COMPLAINT CONTROL NUMBER: 27-AS-20250424151715
FACILITY NAME:EL RIO MEMORY CARE COMMUNITYFACILITY NUMBER:
502700235
ADMINISTRATOR:THERESA PETTAPIECEFACILITY TYPE:
740
ADDRESS:2828 HEALTHCARE WAYTELEPHONE:
(209) 543-3805
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:72CENSUS: 61DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Reshmika Sharma, Director of Resident ServicesTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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 Staff restrained resident in care.
INVESTIGATION FINDINGS:
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On 7/24/25 Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived unannounced at the facility to deliver the findings on a complaint submitted on 4/24/25. The LPA and LPM met with Reshmika Sharma and explained the purpose of the visit. The LPA had conducted inspections of the facility, interviews with residents and staff, and records review to investigate the two allegations.

Allegation: Staff restrained resident in care.
On 6/17/2025, LPA Lindstrom visited the facility and observed ten residents seated in rows in wheelchairs with a brake applied at a trivia group activity. She also observed at least half a dozen residents in wheelchairs without brakes on who were sitting elsewhere in the facility or propelling themselves forward through common areas with their feet.


Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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 5
Control Number 27-AS-20250424151715
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: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235
VISIT DATE: 07/24/2025
NARRATIVE
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On 7/14/2025, LPA Lindstrom interviewed three Staff (S1, S2, and S3). S1 stated that wheelchair brakes were never applied for staff convenience, only for safety during meals, transfers, and group activities. S1 stated that staff were always present during these times to release the brakes when residents wanted to leave. S2 stated that staff applied wheelchair brakes at the dining room tables to prevent wandering and during group activities to keep residents in place. S3 stated that staff was not supposed to lock wheelchairs; staff let residents have free will.

On 7/16/2025, LPA Lindstrom interviewed three Staff (S3, S4, and S5). S3 stated that staff locked one wheelchair brake during meals to reduce fall risks. S3 explained that one unlocked brake allowed residents to still self propel, which let staff know they wanted to leave. S4 stated that wheelchair brakes should be locked during resident transfers to and from wheelchairs. S5 stated that brakes were not to be used except for safety during meals, activities, and dangerous situations.

On 7/16/2025, the LPA interviewed two Residents in wheelchairs (R1 and R2). R1 stated that he had gotten all the help he needed from staff with his wheelchair and that he had no complaints. R2 stated that he got the assistance he needed from staff with his wheelchair.

On 07/16/2025, LPA Lindstrom observed four residents in wheelchairs watching a movie and eight residents in wheelchairs singing together in a group activity, all with no brakes applied.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250424151715
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: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
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This 9099D was written in error.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5