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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701172
Report Date: 05/14/2025
Date Signed: 05/14/2025 11:46:10 AM

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
05/09/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20250509164915
FACILITY NAME:YOUNG AT HEART RCFE NO.5 INCFACILITY NUMBER:
342701172
ADMINISTRATOR:SISAYAN, ISAGANIFACILITY TYPE:
740
ADDRESS:8039 CAYMUS DRIVETELEPHONE:
(916) 681-3689
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Glenda MolinyaweTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Personal Rights: Staff handle resident in a rough manner.
Neglect/Lack of Supervision: Staff did not prevent residents from harming another resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Young at Heart RCFE No. 5. on 5/14/25 at 9:00am to inform the licensee of complaint allegations mentioned above.

During this investigation LPA Gould interviewed one staff member, three residents and R1's authorized representative (A1) (See confidential name list LIC-811 dated 5/14/25). LPA attempted to contact RP without success.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations.

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
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 2
Control Number 27-AS-20250509164915
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: YOUNG AT HEART RCFE NO.5 INC
FACILITY NUMBER: 342701172
VISIT DATE: 05/14/2025
NARRATIVE
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 The alleged victim, (R1) denied the allegations and provided contradictory statements to the alleged violations. R1 provided statements that staff are kind and gentle when assisting the resident and denied any conflicts or altercations with other residents. All other residents and staff interviewed denied the allegations and provided statements of quality care and supervision. Interviews with A1 support the findings as A1 provided statements to LPA that the facility is providing good care and supervision to R1. A1 has no concerns regarding the care provided to R1

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights and neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2