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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 07/17/2025
Date Signed: 07/17/2025 02:56:25 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
05/06/2025 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250506081827
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: 6DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Administrator: Lita SiebenthalTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not ensure that resident's dietary needs were met
Staff spoke inappropriately to resident
Staff not accommodating residents needs
INVESTIGATION FINDINGS:
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On 7/17/2025 at 12:45 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to the facility to conduct a complaint visit. LPA met with administrator Lita Siebenthal and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 6. A brief interview with conducted with Lita Siebenthal.

Allegation: Staff did not ensure that resident's dietary needs were met
It was alleged that staff did not ensure that resident's dietary needs were met. This investigation consisted of interviews with residents and care, records review, and facility observations. On 5/7/2025 LPA’s Pang Lee and Shakaricka Hughes conducted an unannounced facility visit. Interview with 2 out of 5 residents indicated that residents have no concerns about their dietary needs not being met. Additionally, a review of resident (R2) LIC 602A Physician’s report indicates that R2 has a diabetic diet. A review of the facilities meal menu provided was sufficient in meeting the dietary needs of resident (R2).
Continuation- 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 5
Control Number 27-AS-20250506081827
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: 07/17/2025
NARRATIVE
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 On 7/17/25 LPA Hughes conducted a follow-up facility visit and observed the facility refrigerator 2-day perishables food supply. Two-day perishables in the facility refrigerator were observed pre-made with dates on the containers; food was observed appropriate for residents with specific dietary needs. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

Allegation: Staff spoke inappropriately to resident

It was alleged that staff spoke inappropriately to resident. This investigation consisted of interviews with witnesses, facility staff and residents. On 4/29/2025, during a visit to the facility witness (1) stated that they observed an interaction between facility administrator and resident (R2) stating that facility administrator spoke inappropriately to resident (R2). Additionally, interview with R2’s private caregiver reflected that there were no concerns of staff speaking inappropriately to residents in care. Interview with 1 facility staff indicated that, staff have not spoken to residents inappropriately and have not witnessed other staff speak to residents inappropriately. Interview with resident (R2) reflected no concern with facility staff speaking inappropriately themselves or other residents in care. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

Staff not accommodating residents needs

It was alleged that staff are not accommodating residents needs. This investigation consisted of interviews with facility staff and residents. On 7/1/2025 LPA Hughes conducted a follow-up visit to the facility. Interview with residents in care reflected that 3 out of 5 residents in care have no concern with staff not accommodating the needs of residents in care. On 7/17/2025 LPA Hughes conducted a follow-up visit and observed facility staff assisting residents with seating for lunch. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

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 violations occurred.


SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/06/2025 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250506081827

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: 6DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Administrator: Lita SiebenthalTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff not administering resident’s medication properly
INVESTIGATION FINDINGS:
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On 7/17/2025 at 12:45 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to the facility to conduct a complaint visit. LPA met with administrator Lita Siebenthal and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 6. A brief interview with conducted with Lita Siebenthal.

Staff not administering resident’s medication properly
It was alleged that staff is not administering resident's medication properly. This investigation consisted of records review, and interview with staff. On 5/7/2025 LPA Pang Lee and Shakaricka Hughes conducted an unannounced visit to the facility. A review of residents records indicated that there were discrepancies with 3 out 5 residents medications. It was observed that Resident (R1) medication storage had medications missing, and medications were not in their original packaging.

Continuation: 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250506081827
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: 07/17/2025
NARRATIVE
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Resident (R2) had (1) medication that was signed off as administered but the medication could not be located in the facility, R2’s Centrally Stored Medication Destruction Record (CSMDR) could not be located in the resident’s medication log. Resident (R3) had inconsistencies in the start date and amount of medication on hand. Interview with facility staff revealed that there were known discrepancies in medication administration, which had not been addressed or corrected at the time of the facility observation. This allegation was observed not in compliance with Title 22 regulations 87465(a)(6) Incidental Medical and Dental Care. The facility did not ensure that an accurate record of residents medication was maintained at the facility.


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 Lita Siebenthal 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: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250506081827
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2025
Section Cited
CCR
87465(a)(6)
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Incidental Medical and Dental Care 87465. (a) A plan for incidental medical and dental care shall be developed by each facility.(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained..This requirement was not met as evidenced by:
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Licensee will ensure that the facility is in compliance with Title 22 regulation 87465 Incidental Medical and Dental Care. Licensee will ensure resident medication logs and CSMDR are accurately recorded and available. Licensee will provide a signed statement...
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Licensee did not ensure that a accurate record of resident's medication were accurately maintained in the facility. R1,R2,R3 medication logs were not accurately recorded, CSMDR record was missing from R2 resident medication log, including inconsistencies in the start date and amount of medication on hand.
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of understanding and provide proof of training related to Incidental Medical and Dental Care to LPA Hughes by 7/24/2025.
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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: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5