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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 032701408
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:30:57 PM

Unsubstantiated


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
10/07/2024 and conducted by Evaluator Arvin Villanueva
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241007134422
FACILITY NAME:JACKSON HILLS ASSISTED LIVING LLCFACILITY NUMBER:
032701408
ADMINISTRATOR:JORDAN, JAMESFACILITY TYPE:
740
ADDRESS:223 NEW YORK RANCH ROADTELEPHONE:
(916) 212-0275
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:70CENSUS: 52DATE:
01/17/2025
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Cheryl BoehmeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff coerced a dementia resident into signing legal documents.
INVESTIGATION FINDINGS:
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On 1/1/7/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a follow up complaint visit regarding the allegation noted above. LPA met with Cheryl Boehme and stated the purpose of this visit.
The investigation into the allegation that facility staff coerced a resident (R1) with dementia into signing legal document consisted of interviews and document reviews.
Interview with an involved party (W1) confirmed that they were contacted by the Ombudsman to help with R1's situation. W1 described R1 as coherent during the document signing, able to recognize people with some reminders, and able to clearly express intentions despite having dementia. R1 executed a power of attorney for medical rights, with those rights being returned to R1 until a new fiduciary was appointed. W1 mentioned that R1 had concerns about financial exploitation by previous fiduciaries. W1 also confirmed that facility staff (S2), was present as a witness during the signing to ensure transparency. W1 emphasized that there was no evidence of coercion in R1's decision-making.
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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
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 2
Control Number 27-AS-20241007134422
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: JACKSON HILLS ASSISTED LIVING LLC
FACILITY NUMBER: 032701408
VISIT DATE: 01/17/2025
NARRATIVE
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Interview with S1 who noted that R1, suffering from dementia. Furthermore, there is an ongoing investigation by Adult Protective Services (APS) concerning R1’s property and allegations against R1’s Power of Attorney (POA), regarding financial mismanagement. The Ombudsman intervened to protect R1’s bank account by making it solely under R1’s name, excluding POA and another individual, while the next court hearing is scheduled for January 2025.

Additionally, other interviews indicated that facility staff acted accordingly to protect R1 when allegations of elder abuse were made against R1’s POA.

Document review revealed that a judge had ruled that the documents signed under the Ombudsman’s direction at Jackson Hills were invalid, and those documents prepared in 2022 were still considered valid. A further document review confirmed that R1 has advanced dementia and was assessed as no longer competent to make medical or financial decisions independently. R1 was determined to need an attorney or legal agent present for any decision-making.

Although R1 suffers from advanced dementia, the signing of legal documents was deemed necessary by the Ombudsman due to allegations of elder abuse against R1’s POA. Interviews revealed that facility staff acted as witnesses during the signing process and were following the Ombudsman’s instructions to ensure R1's safety and protection. The facility was protecting R1 from the allegation of financial exploitation and ensured that no coercion occurred during the signing of the legal documents. There is no clear evidence to support the claim that facility staff coerced R1 into signing the documents, therefore, the allegation was deemed UNSUBSTANTIATED. Note that an unsubstantiated finding means 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.

Based on today’s visit, no deficiencies are being cited.

Exit interview was conducted with Cheryl Boehme and a copy of this report and appeal rights were provided.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2