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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002916
Report Date: 12/29/2025
Date Signed: 12/29/2025 03:25:55 PM

Unsubstantiated


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
12/01/2025 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20251201101836
FACILITY NAME:ROSEVILLE RESIDENTIALFACILITY NUMBER:
315002916
ADMINISTRATOR:MENDOZA, AILEEN MAEFACILITY TYPE:
740
ADDRESS:7048 CASTLE ROCK WAYTELEPHONE:
(916) 619-7673
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 4DATE:
12/29/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Aileen Mendoza and Tony Hoang, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not refund authorized representative after residents death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA spoke with Administrator, Aileen Mendoza and Tony Hoang, during today's inspection.
A complaint was received alleging staff did not refund authorized representative after residents death. The responsible party removed most personal belongings on November 16, 2025. Hospice and a durable medical equipment provider retrieved some equipment on November 17 and November 20, respectively. However, documentation confirms that the resident’s hospital bed remained in the facility and was never removed.
The Admission Agreement, signed and initialed by the responsible party, specifies that refunds are issued only after full removal of personal property. Facility records, logs, door camera images, and written communications show that the responsible party acknowledged responsibility for arranging removal of the bed and that the bed belonged to the resident. LPA was unable to obtain a receipt from the DME company showing ownership of the bed. Because the bed remained on site, the refund condition was not met.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
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 59-AS-20251201101836
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: ROSEVILLE RESIDENTIAL
FACILITY NUMBER: 315002916
VISIT DATE: 12/29/2025
NARRATIVE
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Although no refund was owed under the agreement, the facility offered and issued a $750 courtesy refund, which the responsible party accepted in writing. Based on the evidence reviewed, the facility complied with contractual and regulatory requirements. The allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2