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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 576804173
Report Date: 04/24/2026
Date Signed: 04/24/2026 04:00:18 PM

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
01/23/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260123152701
FACILITY NAME:GRAND RIVER VILLAFACILITY NUMBER:
576804173
ADMINISTRATOR:LUCELI SOTO-LUISFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BLVDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:43CENSUS: 20DATE:
04/24/2026
UNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Robert Godfrey, Regional AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff sexually abused resident.
Staff does not accord resident privacy.
Staff isolates resident.
INVESTIGATION FINDINGS:
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On 04/24/2026, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the investigation regarding the above allegations and met with Regional Administrator Robert Godfrey.

The Department conducted an investigation regarding the allegation Staff sexually abused resident and determined that Resident (R1) failed to disclose being raped or sexually assaulted when interviewed. The reporting party was unable to provide any information or evidence to support R1’s allegation. Interviews of two residents failed to provide information to support the allegation and/or any allegations or complaints similar in nature. Interviews with four staff, including the Administrator, failed to reveal any information or evidence to support the allegation.

Continued on 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
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 2
Control Number 21-AS-20260123152701
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: GRAND RIVER VILLA
FACILITY NUMBER: 576804173
VISIT DATE: 04/24/2026
NARRATIVE
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Continued from 9099...

According to West Sacramento Police Department, an attempt to interview R1 was initiated by the responding officer but R1’s response to questions was incoherent and rambling. Based on statements made by residents, staff, and R1, and failed investigative efforts by police to substantiate the allegation, no information or evidence was uncovered to support the allegation.

The complaint alleges that Staff does not accord resident (R1) privacy. The complainant stated that R1 at times complains that they have too many visitors and is overwhelmed. LPA observed that R1 had visitors including family, church members, and health care providers. There was no record of R1 refusing the visits of staff or visitors. In addition, LPA observed on 01/26/2026 and 02/03/2026 that the door was closed during visits by staff and health care workers. Based on LPA’s observations and interviews the allegation that Staff does not accord R1 privacy is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to verify the allegation therefore the allegation is UNSUBSTANTIATED.

The complaint alleges that Staff isolates resident. The complainant stated that R1 feels isolated although complainant reported that R1 has 2 volunteers, a chaplain, a social worker, Home Health Aides and an RN who visit R1 plus visits from family and friends from church. Staff also reported that R1 uses a phone in their room to make and receive calls. In addition, staff reported that R1 is taken to the dining room for meals when they request. Based on LPA’s observations on 01/26/26 and 02/03/2026, interviews with staff, home health aides and review of Visitor Sign-In Sheets the allegation that Staff isolates resident is UNSUBSTANTIATED.

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

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
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