342701143-5-13-2026-27-AS-LKIG-DUAMEA-20260521093225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701143
Report Date: 05/13/2026
Date Signed: 05/13/2026 03:56:42 PM

Unsubstantiated

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
04/01/2026 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20260401103505

FACILITY NAME:	GROVE ST CARE HOME, LLC		FACILITY NUMBER:	342701143
ADMINISTRATOR:	SANDOVAL, MANUEL ALBERTO		FACILITY TYPE:	740
ADDRESS:	9189 GROVE ST.		TELEPHONE:	(916) 686-2859
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Manuel Sandoval		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff are physically/verbally abusing resident.
Staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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On 5-13-2026 at 1:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the allegations noted above. LPA met with Administrator Manuel Sandoval and explained the purpose of the visit. LPA conducted additional interviews with three residents in care as part of this continuing investigation. The full investigation consisted of other interviews with four staff members as well as facility file documentation review of physician's report, medication log sheets, needs and service plan, incident reports, medical records, and additional text messages submitted by licensee pertaining to resident1(R1). Additionally, LPA conducted facility observation on 5-13-2026.

Allegation: Staff are physical/verbally abusing resident. LPA conducted interviews and record reviews as noted above. Based on interviews conducted, there is no corroborated statements or evidence to prove resident1 (R1) or other residents in care have been physically or verbally abused by staff. LPA observed during a visit on 5-13-2026 staff assisting residents appropriately and timely including providing meals and other care needs. {Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260401103505

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: GROVE ST CARE HOME, LLC	FACILITY NUMBER: 342701143
	VISIT DATE: 05/13/2026

NARRATIVE

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Interviews conducted with residents and staff revealed staff interactions as adequate and meeting the needs of residents in care. LPA did not observe any red marks or other types of bruising on residents in care during the observation. Documentation review indicated resident1 (R1) was admitted to facility with a diagnosis of Schizophrenia. Additional documentation review revealed no further evidence of physical or verbal abuse towards residents. An interview with R1 did not reveal conclusive evidence of staff physically or verbally abusing resident in care. As a result, there is not a preponderance of evidence to conclude staff have physically or verbally abused any residents in care, therefore, this allegation is UNSUBSTANTIATED.

Allegation: Staff did not seek medical attention in a timely manner. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews, it was revealed that on or about 3-25-2026, resident1 (R1) was experiencing chest congestion and weakness. As a result, staff on duty called 911 for assistance and R1 was admitted to a local hospital for further treatment and diagnosed with pneumonia and slow heart rate. Additional review of text messages between Administrator and responsible party indicate that on 3-25-2026, a communication was made by Administrator to responsible party to inform of R1's symptoms and need for 911 services performed. Additional interviews and record reviews further revealed R1's history of pneumonia and need for hospitalization, and staff response in an adequate and timely manner. Additional interviews revealed staff in general has met residents' needs in a timely and adequate manner with no corroborated evidence to the contrary. As a result, there is not a preponderance of evidence to conclude staff did not seek medical attention in a timely manner, therefore, 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: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

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