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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004929
Report Date: 07/20/2026
Date Signed: 07/22/2026 03:37:08 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
03/24/2026 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260324091142
FACILITY NAME:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:4CENSUS: 3DATE:
07/20/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cecilia Candido and Noellee CandidoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff do not keep facility free of pests

Facility staff did not ensure that resident's oxygen needs are not met

Facility staff accepted a resident with a higher level of care

Facility staff used furniture to block resident from getting out of bed
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 07/20/2026 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Kulich who were met by the facility designated Administrator, Cecilia Candido, who was interviewed at this time.
Current census was 3 residents.
The purpose of this visit was to deliver the findings of this investigation to this facility, and its representative, at this time.
Based on interviews conducted during the course of this investigation, it was learned that the presence of cockroaches and other bugs/insects were present in the kitchen area and near the facility entrance. It was also observed that the food being left out and the amount of food items which were not properly stored led to the presence of bugs/insects to be present at this time.
Based on interviews conducted during the course of this investigation, it was learned that chairs and other furniture items were being placed around the bed of a resident to prevent them from getting up and out of bed. It was learned that this was observed on several occasions and the practice was still being employed even after it was brought to the attention of the facility designated Administrator that this was a violation of
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
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 4
Control Number 27-AS-20260324091142
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: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
VISIT DATE: 07/20/2026
NARRATIVE
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the resident’s personal rights. It was learned that this resident was beyond the level of care that could be provided by the current facility since this resident was unable to independently transfer or reposition in bed. It was learned that this resident required assistance with transferring and repositioning which was unable to be met by the current staff who were unable to properly physically assist this resident when needed.
Based on interviews conducted during the course of this investigation, it was learned that a resident, R1, was in need of oxygen. It was learned that the machine had to plugged in and turned on so that the resident could wear the mask to receive the oxygen. It was learned that on multiple occasions, the oxygen mask for the resident was not on her face while the machine was not turned on.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20260324091142
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: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2026
Section Cited
CCR
87618(b)(1)
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In addition to Section 87611(b), the licensee shall be responsible for the following:
(1) Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders.
This facility was found to be deficient as evidenced by observations that a resident
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The facility designated Administrator stated that all residents should be afforded all of their personal rights at all times. A statement of correction, along with proof of updated staff training, for no less than (1) hour in duration, on the topic of care and supervision related to resident oxygen use, will be
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was unable to use and manipulate their oxygen machine to make sure that they were receiving it as prescribed by their licensed medical professional which posed a immediate threat to the Health, Safety, and Personal Rights to all residents in care.
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completed and submitted into CCL by the due date for review by this LPA.
Type A
07/21/2026
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This facility was found to be deficient as evidenced by the presence of bugs and
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The facility designated Administrator stated that the kitchen area will be cleaned and kept clear of any old food items. A statement of correction, along with photos of the cleaned and cleared kitchen area, will be completed and submitted into CCL. In addition, a consultation will be made with the local
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insects at the front door and in the kitchen area as well which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.
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pest control company to show that this facility is free of any pests or insects at that time. A statement of correction, along with updated consultation paperwork, will be completed and submitted into CCL by the due date for review by this LPA.
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: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20260324091142
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: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2026
Section Cited
CCR
87468.1(a)(6)
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Personal Rights of Residents in All Facilities
To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect
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The facility designated Administrator stated that all residents should be afforded all of their personal rights at all times. A statement of correction, along with proof of updated staff training, for no less than (1) hour in duration, on the topic of residents personal rights will be completed and submitted into
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residents, or barring windows against intruders, with permission from the Department.
This facility was found to be deficient as evidenced by blocking in a resident in their bed with chairs and other furniture posing an immediate threat to the Health, Safety, and Personal Rights of all residents in care.
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CCL by the due date for review by this LPA.
Type A
07/21/2026
Section Cited
CCR
87459(a)(4)
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Functional Capabilities
The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:
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The facility designated Administrator stated that all residents' needs should be addressed and met by all facility staff at all times. A statement of correction, along with an updated LIC 500 for additional staff hires, will be updated and submitted into CCL by the due date for review by this LPA.
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Transferring, including the need for assistance in moving in and out of a bed or chair.
This facility was found to be deficient as evidenced by the inability of the current staff to provide adequate assistance in repositioning or transferring of residents which poses an immediate threat to the Health, Safety, and Personal Rights of all residents 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: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4