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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700883
Report Date: 02/20/2025
Date Signed: 02/20/2025 09:52:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
12/10/2024 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241210110040
FACILITY NAME:DAWSON'S LODGEFACILITY NUMBER:
342700883
ADMINISTRATOR:DAWSON-LACY, VERONICA L.FACILITY TYPE:
740
ADDRESS:5650 MARTIN LUTHER KING JR BLVTELEPHONE:
(916) 421-0233
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:12CENSUS: 7DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Veronica Dawson-LacyTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not notify appropriate parties regarding resident's change in condition
INVESTIGATION FINDINGS:
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On 2/20/2025 at 9:10am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with Administrator Veronica Dawson-Lacy and explained the purpose of the visit. During this investigation, LPA conducted interviews with Administrator and resident1 (R1). Additionally, LPA reviewed facility file documentation including hospital records, treatment plan, resident appraisal, physician’s report, and general care notes all pertaining to R1.
Allegation: Staff did not notify appropriate parties regarding resident’s change in condition. Based on interviews and record reviews as noted above it was determined that on 11-14-24, R1 informed facility administrator she was going to a local store and left facility. At approximately 9:30pm on 11-14-24, R1 returned home and called 911 stating she took 42 aspirin pills while walking back from the store. R1 was transported to a local hospital for services and released early morning of 11-15-25 with transport back to facility.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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
Control Number 27-AS-20241210110040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DAWSON'S LODGE
FACILITY NUMBER: 342700883
VISIT DATE: 02/20/2025
NARRATIVE
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Based on interview and record review, it was revealed that R1’s change of condition due to overdose was reported to R1’s responsible party, but not reported to Licensing department per regulatory requirements. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20241210110040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAWSON'S LODGE
FACILITY NUMBER: 342700883
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements.(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below: (D) Any incident which threatens the welfare, safety or health of any resident…This requirement was not met as evidenced by:
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Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
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 Based on interview and record review, an incident in which R1 overdosed on medication and hospitalized was not reported to Licensing department. This posed a potential health and safety risk to resident 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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 SOUTH 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
12/10/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20241210110040

FACILITY NAME:DAWSON'S LODGEFACILITY NUMBER:
342700883
ADMINISTRATOR:DAWSON-LACY, VERONICA L.FACILITY TYPE:
740
ADDRESS:5650 MARTIN LUTHER KING JR BLVTELEPHONE:
(916) 421-0233
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:12CENSUS: 7DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Veronica Dawson-LacyTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not ensure resident received mental health services
Staff did not prevent resident from an overdose while in care
Staff canceled resident’s mental health appointments
INVESTIGATION FINDINGS:
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On 2/20/2025 at 9:10am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with Administrator Veronica Dawson-Lacy and explained the purpose of the visit. During this investigation, LPA conducted interviews with Administrator and resident1 (R1). Additionally, LPA reviewed facility file documentation including hospital records, treatment plan, resident appraisal, physician’s report, and general care notes all pertaining to R1.

Allegation: Staff did not ensure resident received mental health services. Based on record reviews noted above, it was revealed that Administrator maintained documented evidence of attempts to contact mental health services. Interviews conducted and documentation reviewed revealed attempted contact with mental health services on the dates of 10/4/2024 and 11/22/2024 including pharmacy services and local county contacts. Additional interviews revealed R1 had a previously scheduled psychiatric appointment. As a result, there is a not a preponderance of evidence to conclude staff did not ensure resident received mental health services, therefore, this allegation is UNSUBSTANTIATED. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 27-AS-20241210110040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DAWSON'S LODGE
FACILITY NUMBER: 342700883
VISIT DATE: 02/20/2025
NARRATIVE
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Allegation: Staff did not prevent resident from an overdose while in care. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that on 11-14-24, R1 informed facility administrator she was going to a local store and left facility. At approximately 9:30pm on 11-14-24, R1 returned home and called 911 stating she took 42 aspirin pills while walking back from the store. R1 was transported to a local hospital for services and released early morning of 11-15-25 with transport back to facility. A review of physician’s report for R1 determined R1 is able to leave facility unassisted. Additional interviews conducted revealed facility staff was aware of R1’s general whereabouts. As a result, based on R1’s ability to leave facility unassisted and staffs’ knowledge of R1’s whereabouts after being informed, there is not a preponderance of evidence to conclude staff did not prevent resident from an overdoes while in care. Therefore, this allegation is UNSUBSTANTIATED.

Allegation: Staff cancelled resident’s mental health appointments. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews, it was revealed that R1 has scheduled psychiatric appointments. Additionally, interviews and record reviews revealed staff have made previous attempts to schedule additional appointments for R1. LPA did not observe or receive documented or verbal evidence of any cancelled appointments during this investigation. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.



SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5