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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002920
Report Date: 04/16/2025
Date Signed: 04/16/2025 08:55:31 AM

Unsubstantiated


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
03/03/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250303120651
FACILITY NAME:AIM ELDERLY CAREFACILITY NUMBER:
315002920
ADMINISTRATOR:HARDOSUBROTO, ALFONSUSFACILITY TYPE:
740
ADDRESS:1397 SUN TREE DRTELEPHONE:
(530) 305-8766
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Caregiver Iwan WibonoTIME COMPLETED:
09:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained bruises while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On April 16, 2025, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Caregiver Iwan Wibono.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Resident sustained bruises while in care.
Resident in question moved out of the facility in September 2024 and the department was unable to obtain information regarding the allegation above. Saff and residents interviewed were unable to recall or provide information regarding the allegation above; therefore, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and copy of the report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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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