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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005452
Report Date: 09/18/2025
Date Signed: 09/18/2025 03:06:19 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
05/19/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250519094652
FACILITY NAME:FLORADALE VILLAFACILITY NUMBER:
317005452
ADMINISTRATOR:TIF, EMILFACILITY TYPE:
740
ADDRESS:2688 FLORADALE WAYTELEPHONE:
(916) 543-9029
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 5DATE:
09/18/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator - Emil TifTIME COMPLETED:
02:18 PM
ALLEGATION(S):
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Staff do not provide daily activities for residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 09/18/2025 to complete and deliver findings to a complaint received on 05/19/2025. LPA met with Administrator, Emil Tif and explained the purpose of the visit.

Throughout the course of the investigation, the department conducted interviews and record reviews.

Please continue to LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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
Control Number 59-AS-20250519094652
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: FLORADALE VILLA
FACILITY NUMBER: 317005452
VISIT DATE: 09/18/2025
NARRATIVE
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Allegation: Staff do not provide daily activities for residents in care

During the investigative process it was reported that staff were not providing a variety of activities for the residents. Staff could not provide a calendar with a variety of activities for the residents. LPA observed board games and puzzles in the living room. Per the regulations, the licensee is to provide an extensive list of activities to include games, sports, exercise, community service activities, community events to include concerts, tours, dances, celebrations of special events, etc. The clients have not been provided with a variety of activities as required by the regulations, therefore, this allegation was Substantiated.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

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

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250519094652
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: FLORADALE VILLA
FACILITY NUMBER: 317005452
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/25/2025
Section Cited
CCR
85079((a)(2)(c))
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85079((a)(2)(c) Activities - The licensee shall ensure that planned activities... provided for the clients: Physical activities... games, sports, and exercise. The licensee shall ensure that clients are given the opportunity to attend and participate in community activities...This requirement is not met as evidenced by:
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The administrator agrees to develop a planned activity program, encouraging all residents to contribute to the planning, preparation, and evaluation of the activities.
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Based on observation and interviews conducted, the administrator did not ensure that there is a planned activity program that includes a variety of activities for the clients. This poses a potential health and safety risk to residents in care.
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Documentation of the planned activity program shall be submitted to the licensing agency by 09-25-25
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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: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3