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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 04/24/2025
Date Signed: 04/24/2025 11:40:32 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
11/23/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20241123150713
FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ermelinda SiebenthalTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Neglect/Lack of Supervision:
1) Resident sustained unexplained injuries while in care.
2) Facility is retaining a resident with a higher level of care need.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 4/24/25 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Ermelinda Siebenthal and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the department was unable to corroborate the allegations. The department obtained and reviewed all records from the facility for alleged victim R1 (see confidential names list, LIC 811 dated 4/24/25) and reviewed medical records provided by the hospital. The department has verified the extensive bruising are a result of reported falls and the alleged victims medication which made R1 susceptible to bruising. The department has reviewed R1's fall history and the bruising is consistent with reported falls that ocurred at the facility. Additionally, there were reported concerns for pressure injuries observed on R1. 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: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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-20241123150713
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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
VISIT DATE: 04/24/2025
NARRATIVE
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The department conducted interviews with facility staff and R1's home health providers and all parties interviewed denied the allegations. Home health nurse interviewed denied witnessing pressure injuries on R1 while in their care at the facility. The department has also reviewed R1's medical and facility records to ensure there are no diagnosis or observations that would indicate R1 would require a higher level of care. Resident file review and staff interviews did not indicate R1 was in need of a higher level of care. All staff interviewed provided statements they were able to meet R1's care needs. Interviews with R1's authorized representative did not produce any additional concerns as family members interviewed approved of the care and supervision provided to R1 while in their care.

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 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: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2