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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700783
Report Date: 03/30/2026
Date Signed: 03/30/2026 12:43:03 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
02/13/2026 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20260213101436
FACILITY NAME:PLC 7117 MAIN, LLCFACILITY NUMBER:
342700783
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7117 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
03/30/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Sevrena Miller TIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Staff improperly transferred resident resulting in staff dropping resident.
INVESTIGATION FINDINGS:
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On 3/30/26, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver complaint findings for allegations listed above. LPA and LPM met with administrator, Sevrena Miller during today's visit and explained the purpose of the visit.

The department conducted record review and interviewed residents and staff regarding the allegation. The investigation revealed that on 01/14/2026 resident, R1 sustained a fall during a transfer by staff, S1. A review of R1’s needs and service plan documents R1 requires a 2-person physical assist and notes “always use gait belt”. S1 attempted to transfer R1 without another staff or using a gait belt resulting in R1 falling and causing pain and injury.

Based on the information gathered, 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 LIC 9099-D page.

Exit interview conducted. Appeal rights and a copy of this report were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
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 2
Control Number 59-AS-20260213101436
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: PLC 7117 MAIN, LLC
FACILITY NUMBER: 342700783
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
87468.2(a)(4)
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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, Personal Rights of Residents in All Facilities.....
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. this requirement was not met as evidenced by;
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Licensee/Administrator shall send a letter of understanding of this Regulation and shall conduct all staff training. All POC documents are due by 3/31/26.
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The investigation revealed that on 01/14/2026, resident, R1 sustained a fall during a transfer by staff , S1. A review of R1’s needs and service plan documents R1 requires a 2-person physical assist and notes “always use gait belt”, 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: 03/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2