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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 576803985
Report Date: 07/01/2025
Date Signed: 07/01/2025 10:31:59 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250312143129
FACILITY NAME:PINE TREE GARDENS EASTFACILITY NUMBER:
576803985
ADMINISTRATOR:SALAZAR, MARITZAFACILITY TYPE:
735
ADDRESS:1214 E. 8TH STREETTELEPHONE:
(530) 758-7574
CITY:DAVISSTATE: ZIP CODE:
95616
CAPACITY:13CENSUS: 13DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alexa Guzman, Direct Support Staff, and Maritza Salazar via phoneTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Personal Rights
Licensee is not following care plan
Facility is in disrepair
Licensee is not seeking medical care for client with change of condition
INVESTIGATION FINDINGS:
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On 7/01/2025, LPA Nakagawa arrived unannounced to deliver findings regarding the above allegations and met with Alexa Guzman, Direct Support Staff to discuss the findings. Administrator Maritza Salazar was contacted via phone.

The complaint alleges that the facility is in disrepair. LPA inspected the facility on 3/18/2025, 6/25/2025 and 7/1/2025 and found the facility to be clean and orderly. There was hot and cold running water, lights were on throughout the facility, the washing machine and dryer were operational. Bathrooms had functioning toilets, sinks and showers had hot water (between 105-120 F) and non-slip mats/surface.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 3
Control Number 21-AS-20250312143129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PINE TREE GARDENS EAST
FACILITY NUMBER: 576803985
VISIT DATE: 07/01/2025
NARRATIVE
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Continued from 9099

On 3/18/2025 LPA found the facility to have a new refrigerator and all other major appliances were in working order. The facility grounds were maintained, with no accumulation of debris. LPA found no evidence of facility being in disrepair on either 3/18/2025, 6/25/2025 or 7/01/2025. Although the allegation may have happened there is not a preponderance of evidence therefore the allegation that the facility is in disrepair is UNSUBSTANTIATED.

The complaint alleges that Licensee is not seeking medical care for client with change of condition. LPA reviewed documentation and reports and found that staff were closely monitoring Client (C1) for changes in condition. Records indicate that on 3/03/2025 care staff had been observing and reporting decompensation of C1, supporting C1 with 1:1 staffing interventions as needed. On 3/06/2025 C1 reported inability to swallow medications which was reported to case manager. Other declines such as hygiene compliance were also noted and reported to care team. On 3/07/2025, Licensee and care team made an appointment for C1 to receive medical treatment for 3/10/25. C1 attended appointment and subsequent medical assessment, and hospitalization resulted. Based on the evidence of the care, the Licensee and care team did note changes in C1’s condition and did seek medical care. Facility notified C1’s case worker and conservator. Therefore, the allegation that Licensee is not seeking medical care for client with change of condition is UNSUBSTANTIATED.

The complaint alleges that the clients’ personal rights are being violated; alleging clients have complained about staff being unfriendly, unresponsive, and neglectful towards clients and reporting that some staff do not come out of staff room, yell at clients, and are rude to clients. LPA interviewed 12 of 12 clients and none stated that staff were unresponsive, neglectful or rude. Several clients felt that there were staff members who were not as friendly or personable as other staff members but none of the 12 clients interviewed stated that staff were neglectful or violated their personal rights. Staff stated that all clients have the right to refuse and cannot be forced to attend a program, take medication, or anything else against their will. Client C1 was able to corroborate that they attended the Wellness Day Program only at their will and request. Therefore, the allegation that personal rights were violated is UNSUBSTANTIATED.

Continued on 9099-C(2)

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250312143129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PINE TREE GARDENS EAST
FACILITY NUMBER: 576803985
VISIT DATE: 07/01/2025
NARRATIVE
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Continued from 9099-C

The complaint alleges that Licensee is not following the care plan of C1. The review of the Needs and Services Plan has a goal of attending a group activity 3 times per week, which is voluntary. Based on the statements of C1, staff interview, and care notes the allegation that Licensee is not following care plan for C1 is UNSUBSTANTIATED.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3