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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004461
Report Date: 09/03/2025
Date Signed: 09/03/2025 10:57:33 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
08/28/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20250828093659
FACILITY NAME:GREENSTAR RCFEFACILITY NUMBER:
347004461
ADMINISTRATOR:DAVID M. HOUSTONFACILITY TYPE:
740
ADDRESS:962 GREENSTAR WAYTELEPHONE:
(916) 400-4656
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Angeline KangTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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1) Staff was sleeping while providing care and supervision
2) Staff did not respond timely to a resident's alerts
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Greenstar RCFE on 9/3/25 at to inform the licensee of complaint allegations mentioned above.

During this investigation LPA Gould interviewed The RP, S1 and S2 (See confidential names list, LIC 811 dated 9/3/25). Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA obtained corroborating statements and documentation confirming the staff member present during an overnight shift fell asleep shortly after arriving for an overnight shift and not being aware a resident was in need for staff assistance. Immediately after being made aware of staffing needs the Licensee ensured a new staff member arrived to relieve staff member within 20 minutes. Staff member was reportedly exhausted from a combination of school and work schedules. Per staff records, staff member was drug tested with all results negative. Facility has made changes to staff schedule to ensure all staff members are awake and well rested to ensure the needs of residents are being met. Report Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 3
Control Number 27-AS-20250828093659
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: GREENSTAR RCFE
FACILITY NUMBER: 347004461
VISIT DATE: 09/03/2025
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegations of personal rights are substantiated.

The following deficiencies are cited per California Code of Regulations, TITLE 22.

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

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250828093659
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: GREENSTAR RCFE
FACILITY NUMBER: 347004461
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2025
Section Cited
CCR
87411(a)
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Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... this requirement was not met as evidenced by statements and documentation received corroborating
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Facility has agreed to provide a written plan of steps already taken or will take to ensure the violation does not reoccur.
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staff member fell asleep shortly after arriving on overnight shift and was unable to respond to resident requests for assistance which poses a potential health, safety and personal rights risk to residents in care.
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Type B
09/12/2025
Section Cited
CCR
87464(f)(1)
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Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by statements and documentation received corroborating
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Facility has agreed to provide a written plan of steps already taken or will take to ensure the violation does not reoccur.
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staff member fell asleep shortly after arriving on overnight shift and was unable to respond to resident requests for assistance which poses a potential health, safety and personal rights risk to residents 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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3