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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 03:39:35 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
02/27/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260227111415
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:
03:08 PM
MET WITH:Robert Godfrey, Regional AdministratorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility failed to safeguard residents belongings
INVESTIGATION FINDINGS:
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On 04/24/2026, at approximately 3:08 PM, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete a complaint investigation and to deliver findings. LPA met with Regional Administrator Robert Godfrey.
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The complaint alleges that the Facility failed to safeguard resident’s belongings. The complainant stated that they went to retrieve the chair of Resident (R1) upon their passing but was unable to recover the chair as it was missing. LPA questioned 4 facility staff regarding the chair. 4 of 4 staff stated the chair of resident R1 was at the facility, currently located in the Activities Room.

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-20260227111415
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....

Family members of R1 were asked if they had a picture of the chair but were unable to provide one, but stated “Although the chair (currently in the Activities Room) was similar to that of R1 they did not believe it to be the same. One of two family members stated the one at the facility was more orange than the brown one of R1. The second family member stated that the chair had been labeled and the chair shown had no label and was not in the same condition as the chair belonging to R1. Staff (S1) was able to provide a picture from a year ago in February of 2025. It shows staff member (S2) sitting in a chair that looks very much like the chair identified by staff as R1’s chair, in R1’s room. Although the chair looks like the same chair that is now at the facility, LPA cannot conclusively identify the chair is one in the same without a picture provided from friend or family. LPA examined the chair and found no labels discerning the chair as that of R1: staff were certain it was, but friends and family were not, and there is no record of the chair in R1’s Inventory List.

Based on LPA’s conversations with individuals, both staff and family, and lack of photographic or physical evidence submitted by complainant, the allegation that the facility failed to safeguard resident’s belongings is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation 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)
Page: 2 of 2