502701372-5-5-2026-27-AS-LKIG-DVDQLX-20260625121640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502701372
Report Date: 05/05/2026
Date Signed: 05/05/2026 11:00:30 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
04/08/2026 and conducted by Evaluator Noel Wolf Petersen

COMPLAINT CONTROL NUMBER: 27-AS-20260408115251

FACILITY NAME:	ALAMO HEALTH MANAGEMENT OF TURLOCK		FACILITY NUMBER:	502701372
ADMINISTRATOR:	RICHARDSON, CHELSEY		FACILITY TYPE:	735
ADDRESS:	1617 COLORADO AVENUE		TELEPHONE:	(415) 710-7538
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY:	84	CENSUS: 80	DATE:	05/05/2026
		UNANNOUNCED	TIME BEGAN:	07:09 AM
MET WITH:	Chelsey Richardson		TIME COMPLETED:	07:10 AM

ALLEGATION(S):

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Staff were inappropriately administering insulin to resident resulting in hospitalization
Staff did not allow resident to check blood sugar levels

INVESTIGATION FINDINGS:

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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to investigate a complaint with the above allegations. LPA met with Administrator Chelsey Richardson, to explain the purpose of the visit.

In interview with a client(r1), a claim was made that the staff were overmedicating them, and they belived that they would lose thier housing in the facility if they refused medication. In Interview with 4 Medtech staff and 1 administrator staff, staff have a consensus statement that residents are allowed to refuse insulin, and both have experinced it and documented it, both of those clients are still residents. none of the staff on a shift during the period where the events likely occured can recall a refusal of the insulin by R1. R1 has no internally documented refusals of insulin on the care notes, MARS, or SI reports. R1 does not have a placement contract with term where she would lose her housing at the facility. R1 is not conserved or otherwise unable to refuse medication.

Continued on C. Page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

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-20260408115251

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: ALAMO HEALTH MANAGEMENT OF TURLOCK	FACILITY NUMBER: 502701372
	VISIT DATE: 05/05/2026

NARRATIVE

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In interview with a client(r1), a claim was made that a client was not allowed to use her own blood glucose monitoring to modulate her insulin. In record review, it was learned the client had 4 injections per day at this time, but with a prescribed dose and no order for glucose monitoring or modulation of the insulin. Per the administrator, it is the policy of the facility that without a doctors order for modulating the blood sugar levels, blood glucose monitoring is not conducted by the staff as a service to the client and the supplies for doing so are not released to the affected resident for doing it themselves.

One Staff recalls that shortly after R1 arrived r1 had asked about why thier insulin was not modulated by glucose monitoring, and were told at that time that an appointment with a doctor could be made to address that. The facility staff don't recall R1 asking for a doctor appointment or rasing the issue futher until two months later (later half of february) when the client began experincing constipation and diarrhea. An appointment was made by the facility during the course of the escalation of the constipation/diarrhea incident for r1, and glucose monitioring was added as a prescription, but the insulin order was not changed to be modulated by the results of the glucose monitoring. In record review of r1's mar, Glucose monitoring matierals were provided for the client durring the short period between doctors appointment and the emergency visit where the insulin was discontinued.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

While the specific allegations were unsubstantiated, a supplemental Case Management with concerns related to other personal rights and health related services related to the incident will be addressed in the future due to a lack of time today.

A copy of the report was read and given to the administrator. No citations were issued as part of this visit. appeal rights, exit interview conducted.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

LIC9099 (FAS) - (06/04)

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