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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701285
Report Date: 07/17/2025
Date Signed: 07/18/2025 11:55:38 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
04/08/2025 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250408124304
FACILITY NAME:GATE OF BEAUTIFUL RIPON, THEFACILITY NUMBER:
392701285
ADMINISTRATOR:ELL, NICOLEFACILITY TYPE:
740
ADDRESS:836 SUNRISE AVETELEPHONE:
(209) 614-5171
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: 4DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Nicole EllTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not prevent resident from sustaining multiple falls while in care.
Staff did not prevent resident from sustaining injuries while in care.
Staff are not following facility menu.
Staff are not following a resident's dietary plan.
Staff did not ensure that a resident's catheter was changed in a timely manner.
Staff did not seek medical attention for a resident in care.
Staff are not properly caring for a resident's infection.
Staff are not properly cleaning a resident in care.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 07/17/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Nicole Ell, who was briefly interviewed at this time.
Current census was 4 residents.
The purpose of this visit was to deliver the findings to this facility, and it's representative, from the complaint investigation at this time.
Based on a review of the forms and documents retrieved during the course of this investigation, it was observed that there were (4) residents in care at this time.
It was learned that resident, R1, was often times allowed to act and conduct themself in a more independent manner as consulted and was also being followed by a behaviorist. It was learned that R1 would often times behave in a manner to seek out attention by not listening to requests from facility staff and refuse to engage when assisting with Activities of Daily Living (ADLs). It was learned that these outbursts and behaviors from R1 were to be ignored until R1 calmed down so that a positive discussion could then be held with R1 in
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
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 2
Control Number 27-AS-20250408124304
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: GATE OF BEAUTIFUL RIPON, THE
FACILITY NUMBER: 392701285
VISIT DATE: 07/17/2025
NARRATIVE
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order for facility staff to complete and assist with the resident's care needs.
It was learned that R1 was able to ambulate and move about the facility independently but often times refused to do so. R1 did have the use of a wheelchair and walker at this time.
It was learned that R1 did have a tendency to throw themself on the floor even though R1 was able to get up and move themself off of the floor. By doing this, R1 did suffer lacerations and bruises from self harm and did so even in the presence of the facility caregivers. It was learned that it was very difficult to re-direct and de-escalate behavioral outbursts when R1 got angry. It was learned that the behaviorist recommended that facility staff not engage with R1 when R1 was triggered with their behaviors so that it would slowly calm the situation down by not affirming R1's attention seeking behavior.
It was learned that R2 moved into this facility in the latter part of 2024 but this facility was instructed by R2's attending physician that R2 be placed on a lactose free diet due to health concerns. It was observed that the facility menu did take this into account and the meals that were prepared for this resident reflected this detail even though it was not required that this facility maintained and followed a set menu at all times. It was learned that milk was always offered for all meals if desired by the other facility residents.
Based on a review of the forms and documents retrieved during the course of this investigation, it was learned that R3 had an in-dwelling catheter, upon admission, which required care in cleaning and maintaining.
A review of the medical records for R3 revealed that there was an incident where it was discovered that R3 had sustained a Urinary Tract Infection (UTI) on 01/30/2025. Medical records were reviewed for R3 detailing admission into the local medical institution for treatment and eventual discharge with antibiotics at that time. It was observed that the prior hospital visit conducted for R3 in December 2024 did not present any issues related with the catheter. It was observed that it was noted as being present at that time without any further issues.
It was observed that a care plan was put into place where R3 would receive regular maintenance with R3's catheter and have it removed, cleaned, and re-inserted at the local medical institution on a monthly basis.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.
Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
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 2