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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701533
Report Date: 08/22/2025
Date Signed: 08/22/2025 01:25:01 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
06/16/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250616145518
FACILITY NAME:ALL OUR LOVE SENIOR HOME, INCFACILITY NUMBER:
342701533
ADMINISTRATOR:PANEN, ERICAFACILITY TYPE:
740
ADDRESS:30 TEARPAK CTTELEPHONE:
(916) 479-3916
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 1DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Edgar PanenTIME COMPLETED:
01:38 PM
ALLEGATION(S):
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Staff did not allow resident to access common areas in the facility.
Staff spoke to resident in an inappropriate manner.
Staff did not provide resident with adequate food service.
Staff did not ensure facility was free from pests.
Staff did not ensure facility was properly maintained.
Staff did not ensure kitchen utensils were properly maintained.
Staff did not ensure resident was provided a clean mattress.
INVESTIGATION FINDINGS:
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On Auguest 22, 2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Edgar Panen and explained the purpose of the visit. A brieft conversatoin was conducted via telephone with administrator Erica Panen. LPA Lee explained the purpose of this visit is to deliver complaint findings for the above allegations and went over the allegations with the administrator Panen. The current census is one.

It was alleged that staff did not allow residents access to the common areas in the facility. The investigation included interviews with staff, residents, resident responsible parties, and outside agencies, as well as direct observations. All four staff members interviewed stated that residents are permitted to access all areas of the facility except for the garage, which contains chemical materials. Two residents were interviewed. One of the two residents stated they have no concerns with the allegation.

CONTINUED LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
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 7
Control Number 27-AS-20250616145518
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: ALL OUR LOVE SENIOR HOME, INC
FACILITY NUMBER: 342701533
VISIT DATE: 08/22/2025
NARRATIVE
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Two out of two family members who frequently visit reported that they have observed residents freely accessing the common areas and expressed no concerns. Two out of two representatives from outside agencies confirmed they have witnessed residents in the common areas. During a site visit on 06/18/2025, LPA Lee and Ombudsman Byron Toliver observed a resident in the dining and in the kitchen. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not allow residents to access the common areas in the facility.

An allegation was made that staff spoke to residents in an inappropriate manner. The investigation included interviews with facility staff, residents, resident responsible parties, and outside agencies, along with direct observations. Four staff members were interviewed. All four denied that any staff had spoken inappropriately to residents under their care. Two residents were interviewed. One of the two residents stated they had not witnessed staff speaking inappropriately to residents and expressed no concerns regarding the behavior of facility staff. Two family members reported that they had not witnessed any inappropriate communication from staff toward residents and shared that their experiences have only been kindness from the facility staff. Two representatives from outside agencies stated that they had not observed any instances of inappropriate communication between staff and residents, and they expressed no concerns. Direct observations were made during a site visit. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver, did not observe any inappropriate communication between staff and residents. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff spoke to residents in an inappropriate manner.

It was alleged that staff did not provide residents with adequate food service. This investigation consisted of interviews with staff, residents, and resident responsible party as well at direct observations. Four staff members were interviewed. All four staff denied that staff are not providing adequate food service to residents in care. Two residents were interviewed. One of the two residents stated they have no concern regarding the adequate amount of food being provided and are content with the meals provided.

CONTINUED LIC 9099-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20250616145518
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: ALL OUR LOVE SENIOR HOME, INC
FACILITY NUMBER: 342701533
VISIT DATE: 08/22/2025
NARRATIVE
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 Two family members reported that they also had no concerns about the food provided to the residents in care and stated that meals and snacks were "more than generous." Two representatives from outside agencies stated that they have no concerns with the food service being provided to the residents and have witnesses residents being provided with adequate food. Direct observations were made during a site visit. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver toured the kitchen observed that there was an adequate supply of food, including a minimum of seven days’ worth of non-perishable and two days’ worth of perishable food supplies. Moreover, these supplies were accessible to the residents in care. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not provide residents with adequate food service.

An allegation was made that staff did not ensure the facility was free from pests. The investigation included interviews with facility staff, residents, residents responsible parties, and outside agencies, along with direct observations during two separate site visits. Four staff members were interviewed. All four denied that there was any pest in the facility. Two residents were interviewed. One of the two residents stated they had not witnessed any pest in the facility and expressed no concern. Two family members reported that they had not witnessed any pest in the facility and also have no concern. Two representatives from outside agencies stated that they had not observed any pests in the facility and they expressed no concern. Direct observations were made during two site visits. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver, did not observe evidence of pest in the facility as well as today’s visit, 08/22/2025. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not ensure the facility was free from pest.

It was alleged that staff did not ensure the facility was properly maintained and that staff did not ensure kitchen utensils were properly maintained. The investigation included interviews with facility staff, residents, resident responsible parties, and outside agencies, along with direct observations during two separate site visits. Four staff members were interviewed. All four staff denied that the facility and kitchen utensils are not properly maintained. Two residents were interviewed. One of the two residents stated they had not witnessed the facility and kitchen utensils not properly maintained and expressed no concern.

CONTINUED LIC 9099-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
06/16/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250616145518

FACILITY NAME:ALL OUR LOVE SENIOR HOME, INCFACILITY NUMBER:
342701533
ADMINISTRATOR:PANEN, ERICAFACILITY TYPE:
740
ADDRESS:30 TEARPAK CTTELEPHONE:
(916) 479-3916
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 1DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Edgar PanenTIME COMPLETED:
01:38 PM
ALLEGATION(S):
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2
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9
It was alleged that staff did not dispense resident’s medication as prescribed.
INVESTIGATION FINDINGS:
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On August 22, 2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Edgar Panen and explained the purpose of the visit. A brieft conversatoin was conducted via telephone with administrator Erica Panen. LPA Lee explained the purpose of this visit is to deliver complaint finding for the above allegation and went over the allegation with the administrator Panen. The current census is 1.

It was alleged that staff did not dispense resident’s medication as prescribed. The investigation included interview with facility staff as well as records review. Two residents were interviewed during the investigation. One of the two residents reported that their medications were not being administered according to the physician's orders. On 06/18/2025, LPA Lee, accompanied by Ombudsman Byron Toliver, conducted a site visit.

CONTINUED LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20250616145518
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: ALL OUR LOVE SENIOR HOME, INC
FACILITY NUMBER: 342701533
VISIT DATE: 08/22/2025
NARRATIVE
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 During the visit, LPA Lee and Ombudsman Toliver reviewed residents’ medication on hand and Medication Administration Record (MAR) logs for two residents. The review revealed that resident 1 (R1)’s MAR log was incomplete, with staff initials missing for three separate medications across three different days. Further, a medication audit for R1 showed that the medications listed on the MAR did not match the medications physically present. It was learned that R1 kept part of their medication supply in their personal room, while the rest was stored by the facility in a locked cabinet. This dual storage system contributed to confusion of what R1’s prescribed medications are. A review of R1’s LIC 602 Physician’s Report and LIC 603A Resident Appraisal confirmed that R1 requires assistance with medication management. However, the documents also indicate that R1 is able to manage, administer, and store their own medications, creating confusion around the level of responsibility shared between R1 and the facility as R1 stores some of R1’s medication in R1’s room and the facility store some of R1’s medication in the facility lock cabinet. During the interview process, facility administrator Erica was unable to clearly state which medications were currently prescribed to R1. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was able to corroborate the allegation that staff did not dispense resident’s medication as prescribed.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff Edgar Panen and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20250616145518
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: ALL OUR LOVE SENIOR HOME, INC
FACILITY NUMBER: 342701533
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
CCR
87465(c)(2)
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87465(c)(2) 87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication…
(2) Once ordered by the physician the medication is given according to the physician's directions.

This was not met as evidence by:
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The administrator will conduct in-service training to ensure that residents’ medications are given to residents per physician’s order. During today’s visit it was learned that R1 has moved out of the facility.
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Based on interviews, record review and auditing residents’ medications on hand there were multiple discrepancies. One resident (MAR) listed medications were not initial as being administered; however, those medications were not found in the residents stored medications box; however, it was listed on the MAR logs as having been administered to the residents throughout the month.
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The administrator will provide LPA Lee with proof of training along with materials used for the training with staff sign-in sheets and a statement of understanding and acknowledgement of the regulation cited. POC due to LPA Lee 09/05/2025 end of day 5:00 PM.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20250616145518
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: ALL OUR LOVE SENIOR HOME, INC
FACILITY NUMBER: 342701533
VISIT DATE: 08/22/2025
NARRATIVE
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Two family members reported that they also have no concern with the facility and kitchen utensils not properly maintained and expressed that the facility is very clean, feels very lucky and comfortable that their loved one is house at the facility and feels that the residents is very well taken care of. Two representatives from outside agencies stated that they had not observed any concerns with the facility not being maintained. Direct observations were made during two site visits. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver observed that the facility was clean, free of odors, and in good repair. No signs of mold were found in the residents’ showers, under the kitchen sink, or on the windowsills. No cracks were observed on the floors throughout the facility, and the bathroom walls showed no signs of peeling. The dishwashing sponge was also observed to be clean. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegations that staff did not ensure the facility was properly maintained and that staff did not ensure kitchen utensils were properly maintained.

It was alleged that staff did not ensure residents were provided with clean mattresses. The investigation included interviews with facility staff, residents, responsible parties, and outside agencies, along with direct observations during two separate site visits. Four staff members were interviewed. All four denied residents are not provided with clean mattresses. Two residents were interviewed. One of the two residents stated they have no concern that they are not provided with a clean mattress. Two family members reported that they had not witnessed residents with unclean mattresses and had no concern. Two representatives from outside agencies stated that they had not observed any residents with unclean mattresses and they expressed no concern. Direct observations were made during two site visits. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver inspected mattresses in six resident rooms and did not observe the mattress to be dirty and having any stains as well as today’s visit, 08/22/2025. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not ensure residents were provided with clean mattresses.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.



Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.
A copy of this report was provided to care staff Edgar at the end of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7