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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920122
Report Date: 10/14/2025
Date Signed: 10/15/2025 09:18:20 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, 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
07/21/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250721130754
FACILITY NAME:ANGELS SUNRISE VILLA INC.FACILITY NUMBER:
315920122
ADMINISTRATOR:KUMAR, ALPESHFACILITY TYPE:
740
ADDRESS:2060 DONOVAN DRIVETELEPHONE:
(916) 847-0842
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 6DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Administrator - Alpesh KumarTIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Facility is storing expired food in the facility
INVESTIGATION FINDINGS:
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Observations of the kitchen and food storage areas indicated that facility had expired foods that were being served to the residents in care. On 07/22/2025 LPA observed expired milk in the fridge and expired canned goods in the pantry. Interviews conducted with S1 and S2 indicated that there was expired food available for resident consumption. Staff stated that administrator had gone through all the food in the fridge and cabinets to remove all expired foods. Therefore, the allegation that staff are serving expired food to residents in care is substantiated.

Based on observation and interviews conducted, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page.

Appeal rights provided. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 5
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
07/21/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250721130754

FACILITY NAME:ANGELS SUNRISE VILLA INC.FACILITY NUMBER:
315920122
ADMINISTRATOR:KUMAR, ALPESHFACILITY TYPE:
740
ADDRESS:2060 DONOVAN DRIVETELEPHONE:
(916) 847-0842
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 6DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Administrator - Alpesh KumarTIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Facility confiscated toiletries
INVESTIGATION FINDINGS:
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During the investigation, LPA toured facility with Administrator. LPA observed a cart filled with toiletries, including toilet paper, wet wipes, and hand sanitizer. LPA also observed extra rolls of toilet paper and 20 boxes of wet wipes in the garage. S1 stated that toilet paper had to be removed from the bathroom due to R2 trying the flush the entire roll. On 10/02/25 S1 stated that every resident needs toileting assistance, so they take the cart with them when providing assistance.

Based on the investigation, observations and interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 5
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
07/21/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250721130754

FACILITY NAME:ANGELS SUNRISE VILLA INC.FACILITY NUMBER:
315920122
ADMINISTRATOR:KUMAR, ALPESHFACILITY TYPE:
740
ADDRESS:2060 DONOVAN DRIVETELEPHONE:
(916) 847-0842
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 6DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Administrator - Alpesh KumarTIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Personal Rights
Facility is not posting an accurate staffing schedule.
INVESTIGATION FINDINGS:
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Licensed Program Analysts (LPAs) Graham Gunby and Bethany Mirlohi arrived at the facility unannounced and met with Administrator, Alpesh Kumar, to deliver findings for the above complaint allegation.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20250721130754
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: ANGELS SUNRISE VILLA INC.
FACILITY NUMBER: 315920122
VISIT DATE: 10/14/2025
NARRATIVE
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Allegation: Personal Rights

During the investigation LPA reviewed R1’s 602 which indicated the resident is experiencing sundowning symptoms including confusion and disorientation. On 10/02/2025 LPA interviewed R1 in their bedroom. R1 stated that they had been yelled at in the facility, but could not remember who yelled at them. R1 also stated that they had been pushed in the facility, but could not remember who pushed them. LPA also interviewed R2, who stated they have not heard any yelling or seen another resident being pushed. R2 stated that staff does not yell or gets physical with the residents. S1 denied this allegation and reported that residents are treated with dignity and respect.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis.

Allegation: Facility is not posting an accurate staffing schedule

During the investigation interviews with S1 were conducted. S1 provided the LIC500, which accurately showed who was working and at what time. LIC500 showed that at least (1) staff has a first aide certificate at all times. LIC500 showed there are at least (2) staff during the day. S1 stated that if a staff member calls out S1 fills in for the day.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20250721130754
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: ANGELS SUNRISE VILLA INC.
FACILITY NUMBER: 315920122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2025
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a) The total daily diet shall be of the quality...necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This poses an immediate health and safety risk to residents in care.
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Licensee will conduct an audit of all food that is available to clients in care to ensure food is not expired. Licensee will send a statement of understanding regarding regulation to LPA by POC due date.
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This was not met as evidenced by: Observation of multiple expired food items in kitchen and pantry shed that was being served to clients 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: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5