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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004748
Report Date: 07/09/2025
Date Signed: 07/30/2025 06:23:05 AM

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
04/17/2025 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20250417143444
FACILITY NAME:EMPIRE GUEST HOMEFACILITY NUMBER:
507004748
ADMINISTRATOR:JOAN LITTLEFACILITY TYPE:
735
ADDRESS:101 SOUTH G STREETTELEPHONE:
(209) 522-1441
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:23CENSUS: 19DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Joan Little, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff physically assaulted resident, resulting in multiple injuries.
INVESTIGATION FINDINGS:
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On 07/09/2025, LPA Campbell arrived to the facility to close a complaint. LPA Campbell met with Joan Little and explained the purpose of the visit.

Regarding the allegation that staff physically assaulted resident, resulting in multiple injuries, LPA Campbell spoke with Staff 1 (S1) and S2. S2 stated that they had "grabbed" R1 by the wrists and ankles to prevent them going out the window and "set" them onto the bed. The statements from S2 also aligned with R1's report that S2 had "tossed" R1 onto the bed against their will. Images of R1's injuries were also observed..

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiency is being cited on the attached 809-D during this visit.
An exit interview was conducted, and copies of the report and appeal rights left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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 2
Control Number 27-AS-20250417143444
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: EMPIRE GUEST HOME
FACILITY NUMBER: 507004748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2025
Section Cited
CCR
80065(l)
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80065(l) - PERSONNEL REQUIREMENTS - Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice.
This requirement is not met as evidenced by:
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Licensee will provide a memo of understanding regarding regulation 80065(l) and conduct an in service with staff regarding Personnel Requirements. Proof of completion in the form of a statement and sign in sheet will be emailed to LPA Campbell at renee.campbell@dss.ca.gov.
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Based on interviews the licensee did not provide for the care and safety of persons without physical or verbal abuse which poses an immediate Health, Safety and Personal Rights risk to persons 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
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