312701001-2-3-2026-59-AS-TORZ-DR5W2N-20260209155438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312701001
Report Date: 02/03/2026
Date Signed: 02/03/2026 10:52:37 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2026 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20260130124046

FACILITY NAME:	A1 SENIOR CARE 2		FACILITY NUMBER:	312701001
ADMINISTRATOR:	TACANDONG, DAISYREE		FACILITY TYPE:	740
ADDRESS:	2040 SYMPHONY AVE		TELEPHONE:	(916) 472-4543
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	6	CENSUS: 5	DATE:	02/03/2026
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Daisyree Tacandong, Administrator		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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Staff did not refund authorized representative after residents death
Staff did not report incident into licensing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open complaint investigation. LPA met with Administrator Daisyree Tacandong during today's inspection.

LPA investigated allegation, "Staff did not refund authorized representative after residents death". LPA interviewed relevant party in which they stated R1 passed away on hospice services on 1/14/26 and resident's belongings were removed by 1/15/26 but a refund was not issued to R1's responsible party. LPA interviewed Administrator in which she stated she did not refund R1's Responsible party because they signed the admission agreement that they would pay month to month. LPA informed Administrator of regulations and a refund will need to be issued. Allegation was found to be substantiated.

Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260130124046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A1 SENIOR CARE 2	FACILITY NUMBER: 312701001
	VISIT DATE: 02/03/2026

NARRATIVE

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LPA investigated allegation, "Staff did not report incident into licensing". LPA interviewed administrator in which she stated she did not send in a death report into CCL concerning R1's hospice death. Allegation was substantiated.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Copy of report provided to the facility.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20260130124046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A1 SENIOR CARE 2	FACILITY NUMBER: 312701001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/13/2026 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.	1 2 3 4 5 6 7	Administrator to refund R1's responsible party for the fees from 1/16/26 to 1/31/26. Administrator to send LPA a receipt of refund by 2/13/26.
	8 9 10 11 12 13 14	This requirement was not met by: Administrator did not refund responsible party within 15 days of when personal belongings were removed which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 02/13/2026 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.	1 2 3 4 5 6 7	Administrator agrees to send into CCL a death report for R1. Report to be sent into CCL by 2/13/26.
	8 9 10 11 12 13 14	This requirement was not met by: Incident was not reported to CCL which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026

LIC9099 (FAS) - (06/04)

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