576804173-8-7-2026-21-AS-KMOA-DX4U2Y-20260819151245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 576804173
Report Date: 08/07/2026
Date Signed: 08/07/2026 10:03:38 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
02/19/2026 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20260219141943

FACILITY NAME:	GRAND RIVER VILLA		FACILITY NUMBER:	576804173
ADMINISTRATOR:	LUCELI SOTO-LUIS		FACILITY TYPE:	740
ADDRESS:	509 MICHIGAN BLVD		TELEPHONE:	(916) 373-1591
CITY:	WEST SACRAMENTO	STATE: CA	ZIP CODE:	95691
CAPACITY:	43	CENSUS:	DATE:	08/07/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Roberto Negrete, Med. Tech., Robert Godfrey, Administrator informed via phone		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not transfer resident per Care Plan leading to injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nakagawa arrived unannounced at Grand River Villa on 8/7/2026 to conclude a complaint investigation and deliver findings. LPA met with Roberto Negrete, Med. Tech. Robert Godfrey, Administrator was notified by phone to discuss findings.

The complaint alleges that Staff did not transfer resident per Care Plan leading to injury. Resident (R1) requires staff assistance with transferring between bed and wheelchair. Complainant alleges staff improperly transferred R1 causing injury. The Department conducted an investigation which included reviewing records and conducting interviews. Interviews of 5 of 5 staff did not identify how R1 sustained an injury.
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

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-20260219141943

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: 08/07/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from 9099-C)

The Department’s review of medical records were inconclusive to determine who caused the injury to R1. LPA reviewed staff training records and found that 10 of 10 staff have proper training per Title 22 Regulations. LPA was able to interview R1 but R1 was unable to identify how injury occurred.

Based on the Department's investigation unable to identify a witness to who caused injury to R1, and R1 unable to identify a staff who caused how the injury occurred, the allegation that Staff did not transfer resident (R1) per Care Plan leading to injury is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2