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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700225
Report Date: 11/24/2025
Date Signed: 11/24/2025 01:54:44 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
11/20/2025 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251120130750
FACILITY NAME:MONA LIZAFACILITY NUMBER:
392700225
ADMINISTRATOR:SALEH, MOTHANNAFACILITY TYPE:
740
ADDRESS:1552 MIDDLE FIELD AVETELEPHONE:
(209) 910-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 3DATE:
11/24/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ruxandra RiosTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff left residents unsupervised
INVESTIGATION FINDINGS:
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On 11/24/2025, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to this facility to conduct a complaint investigation.

Based on a facility visit conducted by Ombudsman officials on November 20, 2025, at approximately 12:10 p.m., the facility was found to be without staff present. Ombudsman officials checked the premises and confirmed with R1 that S1 had left to go to the store. The facility was secured by the two Ombudsman officials during their visit. The Department was contacted regarding the situation, and law enforcement was notified; however, law enforcement was redirected to an emergency before a report could be made and subsequently left the scene. S1 returned to the facility at 1:02 p.m. and explained they needed to obtain important items. Substantiated
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
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-20251120130750
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: MONA LIZA
FACILITY NUMBER: 392700225
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2025
Section Cited
HSC
1569.321(e)
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HSC 1569.321(e)Basic services requirements: Every facility required to be licensed under this chapter shall provided at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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The administrator will submit a written plan outlining the supervision of residents in care to ensure their overall health, safety, and well-being are being properly monitored.
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This requirement was not met as evidence by a facility visit conducted by Ombudsman officials on November 20, 2025, at approximately 12:10 PM., the facility was found to be without staff present. This poses an immediate health and safety risks to resident in care.
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The written plan to be submitted to the Department by POC due date.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2