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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005124
Report Date: 12/19/2025
Date Signed: 12/26/2025 11:17:22 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
11/03/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20251103101720
FACILITY NAME:COUNTRY MANSIONFACILITY NUMBER:
347005124
ADMINISTRATOR:CENDANA-KEINATH, DIANAFACILITY TYPE:
740
ADDRESS:8920 CASELMAN ROADTELEPHONE:
(916) 689-5456
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 4DATE:
12/19/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Zoilo (John) CendanaTIME COMPLETED:
02:44 PM
ALLEGATION(S):
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Staff hit a resident
INVESTIGATION FINDINGS:
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On 12/18/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Zoilo (John) Cendana (S2) and explained the purpose of the visit. LPA Tamayo called Administrator, Diana Cendana (S1), and left them a voice message informing them of their presence at the facility and purpose of this visit. The purpose of this visit is to deliver findings and close the complaint investigation of the allegation above. A brief interview conducted with S2.

Allegation: Staff hit a resident
It was alleged staff hit a resident, based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. According to the SOC 341 dated 10/30/2025, it was reported that on the Resident (R1) stated that "about a week ago", Staff 3 (S3) "told the client to go to bed and slapped her on the forehead, 3-4 times".

CONTINUED ON 809-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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-20251103101720
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: COUNTRY MANSION
FACILITY NUMBER: 347005124
VISIT DATE: 12/19/2025
NARRATIVE
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Per record review and interviews, R1 did not recall the date of the incident nor the name of staff person's who hit them but was able to point out S3 to S1. Per LIC 500, there were only two night staff on at that time. S1 reported there were no visible injuries and the client did not complain of any pain for R1.

Interviews with three collateral witnesses (P2-P4) and care staff (S1 and S2) informed that R1 has been out of baseline in the past three months and is awaiting psychiatric evaluations. Based on interviews with S1, S2, P1,and P3, R1 has never made allegations of staff hitting them at their day program nor the care home. Additionally, three residents did not corroborate the allegation. S3 declined having ever hit a resident. Per two staff interviews (S1-S2), S3 has not been accused of hitting any other residents in the past. R1 did not respond to interview questions asked by LPA Tamayo on 10/31/25 and 11/7/2025. LTCO (P2) stated R1 did not respond to interview questions on two different attempts. Four out of four facility care staff stated they have not observed staff hit any resident. Interviews with three staff and two residents confirm that the incident was not witnessed.

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 staff hit a resident are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the S2, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2