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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 07/10/2025
Date Signed: 07/10/2025 05:01:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
07/09/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250709102716
FACILITY NAME:ANSEL PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR:PAYNE, KEITHFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: 78DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Keith Payne, Executive DirectorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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9
-Staff does not have criminal background clearance
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Keith Payne, and the Assistant Executive Director, Amanda Farley, to open a complaint investigation and deliver complaint investigation findings regarding the above stated allegation.

During today's visit, LPA conducted interviews and obtained documentation pertinent to the investigation. Interview with ED indicated that staff (S1) is employed in the independent living section of the facility as a transportation driver. S1 provides transportation periodically for residents in the assisted living and memory care sections of the facility. S1 does not have fingerprint clearance or exemption and is not associated to the facility.

Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 59-AS-20250709102716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANSEL PARK SENIOR LIVING COMMUNITY
FACILITY NUMBER: 312700574
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2025
Section Cited
CCR
87355(d)(3)
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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted... (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.
This requirement was not met as evidenced by:
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Facility will ensure that staff member will obtain a criminal background clearance or exemption before transporting residents in assisted living and memory care. Facility will submit to LPA by POC due date.
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Based on interviews conducted, facility did not ensure that a criminal record clearance was obtained for one (1) staff member, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
07/09/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250709102716

FACILITY NAME:ANSEL PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR:PAYNE, KEITHFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: 78DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Keith Payne, Executive DirectorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Facility transportation vehicles/bus are not maintained in a safe operable condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Keith Payne, and the Assistant Executive Director, Amanda Farley, to open a complaint investigation and deliver complaint investigation findings regarding the above stated allegation.

During today's visit, LPA conducted interviews and obtained documentation pertinent to the investigation. LPA was provided a service invoice indicating that a bus maintenance and safety inspection of the facility bus was performed on July 10, 2025. The invoice indicated that the facility bus passed the inspection.

Based on documentation reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3