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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700696
Report Date: 06/11/2025
Date Signed: 06/11/2025 11:43:34 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
05/29/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250529161737
FACILITY NAME:MOUNT HOOD SERENITY CAREFACILITY NUMBER:
342700696
ADMINISTRATOR:NEPOMUCENO, IRENEFACILITY TYPE:
740
ADDRESS:5704 MOUNT HOOD COURTTELEPHONE:
(916) 617-7601
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY:6CENSUS: 3DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator ,Irene NepomucenoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff financially abused a resident in care.
INVESTIGATION FINDINGS:
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 On 06/11/25, Licensing Program Analyst (LPA) Talwinder Bains conducted complaint delivery visit and met with Administrator, Irene Nepomuceno and explained the purpose of the visit.

Throughout the investigation the Department conducted interviews with staff, residents, key witness and reviewed documentation pertinent to the investigation.

The results are as follows:



***Continuation on 9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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-20250529161737
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: MOUNT HOOD SERENITY CARE
FACILITY NUMBER: 342700696
VISIT DATE: 06/11/2025
NARRATIVE
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***Report continued from 9099......

Allegation- Staff financially abused a resident in care.

Department conducted staff and resident interviews and record review to investigate this allegation. On 05/28/2025, during department visit to the facility, law enforcement and resident, R1 and R1's family were present at the facility. Administrator advise RO staff that the facility learned that day (05/28/2025) that R1's family found checks written out to staff, S1 ($400) and a family member of S1 ($500) without the permission of the R1. R1 was interviewed and indicated they did not write the checks nor did give permission for S1 to write the checks to S1 or S1s family member. Record review reflected that both checks were cashed on 05/01/25 and 05/15/25 without R1s consent by S1 and S1s family. Administrator indicated they terminated S1 when they learned of the theft.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff financially abused a resident is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC-9099D.

Appeal rights were provided. Exit interview was conducted and the report was provided to administrator.





SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250529161737
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: MOUNT HOOD SERENITY CARE
FACILITY NUMBER: 342700696
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2-Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1....(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by;
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Licensee/administrator shall send a letter to the department for understanding of this regulation and shall conduct staff training. All POC documentation are due by 06/12/25.
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Record review and interviews reflected that resident, R1 funds were stolen by staff , S1 while living at the facility which poses a immediate health and safety risks 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: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3