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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002961
Report Date: 01/09/2026
Date Signed: 01/09/2026 10:50:22 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, 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
10/06/2025 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20251006152247
FACILITY NAME:SPRING GARDEN CARE HOME, LLCFACILITY NUMBER:
315002961
ADMINISTRATOR:BOT, MELISAFACILITY TYPE:
740
ADDRESS:1901 GREAT DIVIDE CT.TELEPHONE:
(916) 868-4402
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 3DATE:
01/09/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Melisa Bot, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Residents sustained injuries due to staff neglect
Staff left resident in soiled diapers for extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings into the allegation listed above. LPA met with Administrator Melisa Bot during todays inspection.
During the complaint investigation LPA conducted interviews with staff, residents, and relevant parties, and conducted a file review. LPA interviewed the relevant parties in which they stated R1 had sustained injuries to their shins due to staff neglect. Relevant party stated Administrator forced R1 to remain in bed for their injuries to heal. LPA interviewed administrator in which she stated R1 utilized a sit to stand lift that assisted the resident up out of bed with staff help. Administrator stated she believes the injury on resident shins occurred when R1 placed too much pressure on their shins while getting out of the shower. Administrator believes due to R1’s skin being more fragile after a shower, that the sit to stand caused some of R1’s skin to rub off on their shins. Administrator stated she reported the injury to R1’s medical team and treatment started soon after. Administrator stated the injury did not occur from a fall or any other incident.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
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 4
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
10/06/2025 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20251006152247

FACILITY NAME:SPRING GARDEN CARE HOME, LLCFACILITY NUMBER:
315002961
ADMINISTRATOR:BOT, MELISAFACILITY TYPE:
740
ADDRESS:1901 GREAT DIVIDE CT.TELEPHONE:
(916) 868-4402
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 3DATE:
01/09/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Melisa Bot, Administrator TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not meeting resident’s needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings into the allegation listed above. LPA met with Administrator Melisa Bot during todays inspection.

During the complaint investigation LPA interviewed residents, staff and relevant parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated R2 had incidents of vomiting and having diarrhea and R2 did not receive medical attention and it was not reported to the family. LPA interviewed administrator in which she stated R2 did have an episode of vomiting and did not report to hospice or R2’s responsible party. Administrator stated it was one incident and R2 did not have any change of condition due to the vomiting. LPA reviewed resident records, and administrator did not have an up to date needs and service plan reflecting new care. Due to the information gathered LPA finds allegation to be 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
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 4
Control Number 59-AS-20251006152247
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: SPRING GARDEN CARE HOME, LLC
FACILITY NUMBER: 315002961
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2026
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administrator agrees to take a training from an outside agency about meeting resident needs. Administrator to send into LPA a copy of training completion certificate by 1/30/26.
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This requirements was not met by evidenced by: Staff not meeting resident's needs which poses a potential health and safety risk to residents 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: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20251006152247
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: SPRING GARDEN CARE HOME, LLC
FACILITY NUMBER: 315002961
VISIT DATE: 01/09/2026
NARRATIVE
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LPA reviewed resident records and administrator did not have an up to date needs and service plan reflecting new care. In addition, administrator had no documentation or notes reflecting the care being provided. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.

LPA investigated allegation, Staff left resident in soiled diapers for extended period of time". During the complaint investigation LPA interviewed residents, staff and relevant parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated R1 was transferred to their wheelchair in the morning and was never changed or checked for continence care all day. LPA interviewed administrator in which she stated she changed R1 at least 4x a day or as needed. Administrator stated she or her staff have never left resident in their depend all day. LPA reviewed resident records and administrator did not have an up to date needs and service plan reflecting new care. In addition, administrator had no documentation or notes reflecting the care being provided. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.



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

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4