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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002853
Report Date: 10/22/2025
Date Signed: 10/22/2025 03:06:49 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
08/13/2025 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250813104454
FACILITY NAME:SIGNATURE LIVING ON CAMELIA AVENUEFACILITY NUMBER:
315002853
ADMINISTRATOR:OCAMPO, JESSEFACILITY TYPE:
740
ADDRESS:904 CAMELIA AVETELEPHONE:
(916) 899-5880
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 5DATE:
10/22/2025
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Ayunasia "Jacob" SogariTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication
Staff are not meeting resident's dietary needs
INVESTIGATION FINDINGS:
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 On 10/22/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to caregiver, designee to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted interviews.
LPA finds that the allegations cited above are substantiated.
For a period of time there was some confusion and inconsistencies regarding an ointment and cream regiment for a wound to R1's head that lead to R1 not receiving medications as prescribed. The orders have since been clarified and the situation is resolved.
R1 has a physician's order for a high protein diet for healing wounds that have been present at admission. Facility staff did not have a written plan to ensure protein intake and integrated R1's food preferences. A written plan is now in place and R1's preferences are accomodated.
As a result of this investigation, LPA finds allegation 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. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed withdesignee . Copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
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
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
08/13/2025 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20250813104454

FACILITY NAME:SIGNATURE LIVING ON CAMELIA AVENUEFACILITY NUMBER:
315002853
ADMINISTRATOR:OCAMPO, JESSEFACILITY TYPE:
740
ADDRESS:904 CAMELIA AVETELEPHONE:
(916) 899-5880
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 5DATE:
10/22/2025
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Ayunasia "Jacob" SogariTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff do ensure resident's room is clean and sanitary
INVESTIGATION FINDINGS:
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On 10/22/25, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with designee to deliver investigation findings.

LPA reviewed facility records, conducted interviews and conducted inspections.
LPA finds that facility met Tittle 22 requirements.

LPA found that R1's concern regarding possible infection was not supported by the physical evidence. R1's room was observed to be clean and well maintained.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250813104454
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: SIGNATURE LIVING ON CAMELIA AVENUE
FACILITY NUMBER: 315002853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met for R1 based on records and interviews.
This posed a potential risk to R1.
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At this visit, LPA observed that R1 is receiving medications as prescribed.

POC cleared by visit.
Type B
10/23/2025
Section Cited
CCR
87555(b)(7)
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General Food Service Requirements (b) (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met for R1 based on records and interviews.
This posed a potential risk to R1.
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At this visit, LPA observed that R1 is receiving required and preferred foods as prescribed.

POC cleared by visit.
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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: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3