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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700633
Report Date: 07/29/2026
Date Signed: 07/29/2026 01:02:28 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
07/23/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260723162822
FACILITY NAME:BJK RESIDENTIAL CARE IFACILITY NUMBER:
502700633
ADMINISTRATOR:FERNANDO, ROBERTFACILITY TYPE:
735
ADDRESS:656 PARADISE RDTELEPHONE:
(209) 522-1569
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:26CENSUS: 19DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dee Fernando TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Unlawful Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to investigate the above allegtions. LPA met with administrator Dee Fernando and explained the purpose of the visit.
LPA interviewed the administrator, who gave the statement she did not evict R1, she was expressing the opinion of the oncologist that r1 should recive a higher level of care. In a record review of the call log, the administrator expressed that the clients needs were different and he was not welcome back ot the facility, on july 23, and july 25th to Social worker S1 at doctors medical hosptial. LPA gave guidance that even when a administrator determines a client is unsafe to come back to the faciltiy because of changes to thier care, it is an attempt to evict the resident unlawfully if the reappriasal is not completed and a 30 day written notice is not served.
Based on LPAs observations and 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, Cited on following D Page.A copy of the report was read and given to the administrator. appeal rights were provided and exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
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-20260723162822
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: BJK RESIDENTIAL CARE I
FACILITY NUMBER: 502700633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2026
Section Cited
CCR
85068.5(a)(4)
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85068.5 Eviction Procedures (a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit for any of the following reasons:(4) A needs and services plan modification has been performed, as specified in Section 85068.3, which determined that the client's needs cannot be met by the facility and the client has been given an opportunity to relocate as specified in Section 85068.3(b)(3).
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No immediate POC, the client is back in the facility, an currently is not under a lawful or unlawful eviction by the facility. Administrator should review the eviction procedures 85068.5, and send back a signed proof of understanding to the LPA noel.wolfpetersen@dss.ca.gov, by the POC date 7/30/26.
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This requirement was not met based on the evidence: record review of the call log where the administrator records as two of her statements to a socialworker at the hospital that the facility "cannot accept the client at this time" the facility. Not following this requirement posed a health and saftey and personal rights risk to clients 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.
SUPERVISOR'S NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2