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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 07/29/2025
Date Signed: 07/29/2025 01:59:03 PM

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
06/23/2025 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250623163519
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:
07/29/2025
UNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Administrator: Ermelinda SiebenthalTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff are inappropriately restraining a resident in care.
Staff are forcing residents to drink water.
INVESTIGATION FINDINGS:
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On 7/29/2025 at 12:00 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced complaint visit. LPA Hughes met with caregiver Ermelinda Siebenthal and explained the purpose of the visit. The current census is 6 with 2 facility staff.

Staff are forcing residents to drink water
It was alleged that staff are forcing residents to drink 2 to 4 metal cups of water before they are able to leave the table. This investigation consisted of facility observation, and interviews with staff and residents. On 7/1/2025 LPA Hughes conducted a visit to the facility, upon observation of the facility residents were seen sitting at the kitchen table having lunch. Interview with 3 out of 5 residents indicated that they had no concerns regarding being required to drink water. Additionally, an interview with 2 out 3 facility staff indicated that residents are required to consume water as part of their daily routine.

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

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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-20250623163519
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: 07/29/2025
NARRATIVE
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Interview with S1 confirmed that residents, “have too drink water” without additional explanation on why residents are required and cannot choose whether they want to drink water. This was observed not in compliance with Title 22 regulation 87468.2(a)(3) Additional Personal Rights of Residents in Privately operated facilities.The facility did not ensure that residents in care were protected from coercion. Interviews and observations revealed that staff were requiring residents to drink a specific amount of water determined by the facility, and residents were reportedly not permitted to leave the table until they had complied.

Staff are inappropriately restraining a resident in care

It was alleged that staff inappropriately restrained a resident in care. Staff were observed tying an apron around the waist of a resident in care. This investigation consisted of facility observations, interviews with staff, and records review. On 7/1/2025 LPA Hughes conducted an unannounced facility visit and observed resident (R3) sitting at the dining table having lunch, with a helmet on their head. On 7/25/2025 LPA Gould conducted an unannounced facility visit, and observed two gait belts on the kitchen table, per LPA Gould, interview with 1 out of 1 facility staff indicated the belts are used for R1 and R3 to secure the residents to the kitchen table chairs. Facility staff demonstrated how the Gait belts are used on LPA Gould, while sitting at the kitchen table, securing the LPA to the kitchen chair. On 7/29/2025 LPA Hughes conducted an interview with facility administrator, administrator stated that gait belts are used to guide the residents. Resident (R3) wears a gait belt whenever she is unsteady. A review of resident (R3) LIC 603A Resident Appraisal indicates that resident’s ambulatory status and functional capabilities do not require the use of assistive devices such braces or crutches. However, R3 has a physician’s order on file indicating the use of a gait belt for assistance with mobility/transfers with staff support. The order does not specify the use of a gait belt for the purpose of securing the resident to a chair. This was observed not in compliance with Title 22 regulation 87608(a)(5) Postural Supports. The facility did not ensure that residents in care were assisted in a manner that upholds their personal rights, including freedom from being physically restrained or tied.


As a result, these allegations are 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 S 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: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250623163519
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: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2025
Section Cited
CCR
87468.2(a)(3)
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87468.2 Additional Personal Rights for all Residents in Privately operated Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights.(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion,
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Licensee will ensure that the facility is in compliance with Title 22 regulation 87468.2(a)(3). Facility will ensure that residents in care are supported in maintaining adequate hydration while respecting their right to choose when and how much water to consume.
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as citizens and as residents of the facility. Residents shall be free from interference, coercion...
This requirement was not met as evidenced by: Licensee did not ensure that residents in care were protected from coercion being required to drink a specific amount of water.
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Licensee will review the regulations, and provide LPA Hughes with a letter of understanding of the regulation by 08/01/2025.
Type B
08/01/2025
Section Cited
CCR
87608(a)(5)
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87608 Postural Supports.(a)Based on the individual's preadmission appraisal..(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement was not met as evidenced by:
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Licensee will ensure that the facility is in complaince with Title 22 regulation 87608(a)(5). Facility will ensure that residents in care are assisted in a manner that upholds their personal rights. Additionally, Licensee will ensure the use of assistive devices will be used in the manner, instructed by
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Licensee did not ensure that residents in care were assisted in a manner that upholds their personal rights, including freedom from being physically restrained or tied.
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physician orders only. Licensee and facility staff will review regulations regarding Postural support and conduct training with facility staff on the proper use of assistive devices. Licensee will provide LPA Hughes with a letter of understanding of the regulation by 08/01/2025.
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: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3