502701194-11-2-2025-27-AS-LRIS-DNMNKM-20251121093209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502701194
Report Date: 10/31/2025
Date Signed: 11/02/2025 08:46:52 PM

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
08/06/2025 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20250806151041

FACILITY NAME:	HOSPITALITY HOUSE		FACILITY NUMBER:	502701194
ADMINISTRATOR:	PADILLA, LORRAINE		FACILITY TYPE:	740
ADDRESS:	5400 KIERNAN AVENUE		TELEPHONE:	(209) 543-9275
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	80	CENSUS: 43	DATE:	10/31/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Lorraine Padilla		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident sustained a fracture due to staff neglect

Staff does not notify resident's authorized representative regarding incidents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation. LPA Lund met with Administrator Lorraine Padilla and explained the reason for the visit. Census: 43

Resident sustained a fracture due to staff neglect- Based on records reviewed, and interviews with staff and R1’s husband. Department of Socials Services Staff investigated and reviewed medical and facility records. Records state on 8/3/2025, Resident (R1) was hospitalized due to a change in condition. R1 was diagnosed with a right humerus fracture. However, the medical records stated, “Given lytic lesions and imaging findings, there must be consideration of the possibility of pathologic fracture of the humerus related to malignancy.” Medical staff discussed with R1 husband, that hospital staff believed R1 fracture was linked to malignancy.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250806151041

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: HOSPITALITY HOUSE	FACILITY NUMBER: 502701194
	VISIT DATE: 10/31/2025

NARRATIVE

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Hospitality House staff were interviewed, and they all denied R1 suffering any falls or other injuries. R1 husband visited R1 about four times per week. Interviews with R1 husband states about one week prior to 8/3/2025 and noticed R1 kept right arm tucked and did not want anyone to touch R1.R1’s husband touched and “gently squeezed” R1’s arm but didn’t appear to be in pain. Due to not being able to determine how R1 sustained a fracture, the findings are unsubstantiated.

Based on records reviewed, and interviews with staff and R1’s husband on the information provided, it was unclear if resident sustained a fracture due to staff neglect, therefore the allegation was deemed UNSUBSTANTIATED.

Staff does not notify resident's authorized representative regarding incidents- Based on records reviewed, interviews with staff, and R1 husband. LPA Lund reviewed faxed in Unusual Incident/Injury Report dated (LIC624) dated August 5, 2025, 2324. At approximately 2:20 PM R1 had a change in condition and 911 was called and sent to the Hospital Emergency Room for evaluation. On the LIC624 Primary Care Provider and Responsible Party (R1 husband) was notified. Department of Social Service Staff verified that R1 husband was notified.

Based on records review, interviews with clients, reporting party, and staff the information provided, it was unclear if staff does not notify resident's authorized representative regarding incidents, therefore the allegation was deemed UNSUBSTANTIATED.

The Department (CCLD) has found the allegations. Unsubstantiated.

A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a

preponderance of the evidence to prove that the alleged violation(s) occurred. Exit interview was conducted with and report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025

LIC9099 (FAS) - (06/04)

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