<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920212
Report Date: 10/21/2025
Date Signed: 10/21/2025 12:48:04 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
07/21/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250721093511
FACILITY NAME:DELICATE STEMS FOR THE ELDERLY, INC.FACILITY NUMBER:
345920212
ADMINISTRATOR:DOXAN, LAURAFACILITY TYPE:
740
ADDRESS:7008 HERSHBERGER COURTTELEPHONE:
(916) 560-3962
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:5CENSUS: 4DATE:
10/21/2025
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Laura Doxan, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to lack of supervision, resident eloped from the facility.
Unlawful eviction.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint investigation and deliver findings to a complaint received July 21, 2025. LPA initially met with care staff, Novela "Marsha" Pascoe who contacted the Administrator by phone. LPA observed (1) resident watching television in the common area, (1) resident outside on the patio and (2) residents in their rooms. The administrator arrived at 11:20 am to meet with LPA.

During the investigation, LPA interviewed facility staff, (1) resident, (1) placement agency staff, and a family member of resident (R1). Documentation was reviewed relating to (R1), including, but not limited to, monthly progress reports, the admission agreement, emails and text messages between the facility administrator and (R1's) family member, placement agencies and health care providers. The results are as follows:

Resident (R1) moved in on January 15, 2025 and had a diagnosis of Dementia, and needed assistance with dressing, bathing and medications. (R1) was more independent with ambulating, toileting, and eating.
*cont on 9099C-1..

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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 6
Control Number 59-AS-20250721093511
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: DELICATE STEMS FOR THE ELDERLY, INC.
FACILITY NUMBER: 345920212
VISIT DATE: 10/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099C-1... Allegation: Due to lack of supervision, resident eloped from the facility. The allegation states resident (R1) eloped from the facility without staff knowledge on 7/12/25, and the "bell" was not on the door.

The Administrator stated that there were (2) nurses and a care aid present at the facility when (R1) eloped to the neighbor’s house on 7/12/25, and explained the incident was caught on camera. The administrator acknowledged that this incident was reported to the Department and a completed incident report was provided to the Department on 7/23/25, when the complaint was opened.

Staff (S1) stated (R1’s) family member was outside in the car when (R1) exited the facility on 7/12/25. (S1) explained she and the family member circled the block and other neighbors assisted with searching for (5) minutes before locating (R1) in the neighbor's backyard, two houses over. (S1) stated she was serving dinner when (R1) was able to exit through the front door.

A resident who was present on 7/12/2025 stated they recalled (R1) trying to often leave the facility through the front door. This resident confirmed the front door always has a “beep” sound or alert when it’s opened, but it must have been turned off when (R1) was able to leave that day. The resident stated staff was talking to a nurse who was visiting, and the alarm must have been turned back on after (R1) exited the care home.

Interviews also concluded that (R1) tried to leave the facility previously on 7/2/25 but was unable to leave the property before staff were made ware and redirected resident back inside the care home.

Based on information obtained, LPA finds this allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.



*cont on 9099C-2..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20250721093511
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: DELICATE STEMS FOR THE ELDERLY, INC.
FACILITY NUMBER: 345920212
VISIT DATE: 10/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099C-3... Regarding a higher level of care: The family member stated the administrator believes (R1) needs memory care after they eloped on 7/12/25, but (R1’s) Delirium was temporary and was due to a new medication that (R1) is no longer taking and (R1) is "fine".

Documentation was reviewed by the department, including (R1’s) Monthly Progress Report that reflect (R1) becoming increasingly more confused, agitated, aggressive, needing more redirection, staying awake all night, and more difficult to redirect from February 2025 through July 2025. Additionally, the reasons for each hospitalization, on the following dates: June 24-25; July 2- 7; July 12, 2025, are due to the same behaviors.

The administrator emailed LPA on July 16, 2025 regarding the elopement incident on July 12, 2025 which stated: Her daughter sent her out. She was extremely delirious and confused. She was at the facility that day. She also was on the phone with (R1’s) health care plan and spoke with the nurse and physician.

The administrator also provided a letter to the department that she was “reassured that (R1) would be relocated to a different facility that would be more appropriate for (R1’s) psychosis”…and the administrator “had open communication with the agency who is in charge of (R1’s) placement and corresponded with their daughter as well and was told that every effort will be made to make sure (R1) would be relocated to a SNF or a memory care facility”. The administrator stated also in writing that "(R1’s) primary care and psychiatrists have been notified and kept informed” and “requests for medical evaluation or adjustments have been requested” and provided multiple text messages showing conversations between the administrator and (R1’s) placement agencies, health care staff and (R1's) family member. Staff and resident interviews corroborated that (R1) became increasingly confused, agitated, had trouble sleeping at night and was hallucinating until (R1) left the facility and was found in the neighbor's backyard.

On July 16, 2025, the Department was provided with a copy of the 30-day eviction notice issued on July 15, 2025, and it was determined to contain all of the required elements to be a lawful notice; however, due to the resident not being given a 30 day notice until after being told the facility would not allow resident to return on/around July 12, 2025, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

*cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20250721093511
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: DELICATE STEMS FOR THE ELDERLY, INC.
FACILITY NUMBER: 345920212
VISIT DATE: 10/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099C-2- Allegation: Unlawful eviction. The allegation states (R1’s) responsible person received a copy of a 30- day eviction letter on July 15, 2025, to be effective August 14, 2025, and the letter cited two reasons for the eviction 1- nonpayment of rent, and 2- (R1) needing a higher level of care due to delirium.

Regarding the: rent: When moving into the facility, (R1) was participating in a funding program through a placement agency. As part of the contract, effective May 1, 2025, (R1) was to begin paying a monthly co-payment to the facility. Due to non-compliance with meeting monthly co-payments, an “End of Service” notice was issued by the placement agency on/around June 12, 2025 to terminate (R1’s) contract effective July 15, 2025. A representative from the placement agency stated to LPA in July that the decision to terminate the contract was appealed and an extension was granted for (R1) to be able to stay at the facility until August 15, 2025; however, generally when funding stops, it doesn’t matter if the contract has been extended.

The administrator stated she referred (R1’s) family member to the specific program and on/around June 16-18, 2025, a sales representative from this program met with (R1’s) responsible person to sign paperwork so (R1) could be added to their program, once the placement agency ended their contract with (R1). Also at this time, on June 19, 2025, the facility had a change in ownership, and a new facility license was issued. Under the new license, the facility no longer had a contract with this new program. The representative at the placement agency stated to LPA on July 30, 2025, that (R1’s) responsible person needs to contact the new program for assistance in finding a facility that currently contracts with them.

(R1’s) family member stated that the administrator referred (R1) to this specific new program as there are many facilities in the area that participate and claims she was not informed by the administrator that she was not planning on signing a contract with them under the new facility license. Text messages from Thursday, July 17, 2025 document the Administrator telling the family member that “after reading the terms and conditions of the contract with ( ), I’ve decided not to contract with them “ and provided (2) local facility contacts that do contract with the company.

The Administrator stated on July 30, 2025 that she has not received (R1’s) co-pay for July and confirmed that she refused to take (R1) back from the hospital before issuing the 30- day notice on July 15, 2025, due to their behaviors such as eloping and showing physical aggression. The administrator stated she had a 3-way call with (R1's) psychiatrist and family member, and the psychiatrist recommended the facility not take (R1) back until they were evaluated, observed and medications changed were effective. Records show (R1) was taken to the hospital on July 12, 2025 due to being “very confused, disoriented, aggressive and violent the prior days and nights” and interviews confirm (R1) did not return to the facility. *cont on 9099C-3..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20250721093511
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: DELICATE STEMS FOR THE ELDERLY, INC.
FACILITY NUMBER: 345920212
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2025
Section Cited
CCR
87705(d)
1
2
3
4
5
6
7
Regulation 87705 (d) Care of Persons with Dementia- The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator agree to not deactive the door/bell alarm at any time, even when there are multiple visitors.

The correction was done immediately following the incident and all staff are aware.
8
9
10
11
12
13
14
Based on interviews conducted, the Licensee did not ensure that (R1) was not able to leave the facility unassisted on July 12, 2025 (around 5:00 pm) , when (R1) was located in a nearby neighbor's backyard, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
11/04/2025
Section Cited
CCR
87224(a)(1and4)
1
2
3
4
5
6
7
87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5): (1) Nonpayment of the rate for basic services within ten days of the due date, and (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator agree to submit a 3-day eviction notice to the Deparment for review and approval if a resident has psychosis or shows extreme behavior where it is no longer safe for that resident and/or other residents. Also agrees to issue a 30-day as soon as there is a significant change in a resident's behavior if warranted. Documentation that Reg 87224 was read and is understood by 11/4/25.
8
9
10
11
12
13
14
Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was given (30) days notice in writing, while in the hospital, prior to being evicted, which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
The hospital did keep (R1) for a while following the admittance, on 7/12/25, for observation but then was discharged to a higher level of care. The psychiatrist and family member were very involved.
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: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
07/21/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250721093511

FACILITY NAME:DELICATE STEMS FOR THE ELDERLY, INC.FACILITY NUMBER:
345920212
ADMINISTRATOR:DOXAN, LAURAFACILITY TYPE:
740
ADDRESS:7008 HERSHBERGER COURTTELEPHONE:
(916) 560-3962
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:5CENSUS: 4DATE:
10/21/2025
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Laura Doxan, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not have proper training to meet the needs of the resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
During the investigation, LPA interviewed facility staff and reviewed staff records. The results are as follows:

The allegation states that staff do not appear to have the training necessary to appropriately deal with resident (R1) and their exit-seeking behaviors and delusions and sent (R1) to the hospital. Additionally, the “bell” was not on the front door so staff were unaware that (R1) left.

Care staff (S1) stated she received all required training (40 hours) when she started on/around April 2, 2025. (S1’s) training records and another staff's records, were reviewed on October 21, 2025 and found to have been completed in April and May 2025. Both staff have current First Aid/CPR until early 2027. The current license was issued June 19, 2025. An annual inspection was completed under the prior license on February 13, 2025. During this inspection, (6) staff training records were reviewed and found that staff had completed the required initial and/or continuing training. Based on information obtained, this allegation is found to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Exit interview. Copy of report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6