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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701576
Report Date: 05/05/2026
Date Signed: 05/05/2026 01:25:18 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
04/03/2026 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20260403081111
FACILITY NAME:CRYSTAL CREEK SENIOR LIVINGFACILITY NUMBER:
392701576
ADMINISTRATOR:ANGELA RINGUFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS ROADTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 72DATE:
05/05/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jennifer AlmendarezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not ensure resident's dietary needs are met
INVESTIGATION FINDINGS:
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On 5-5-2026 at 11:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with Director of Wellness Jennifer Almendarez and explained the purpose of the visit. During this investigation, LPA conducted interviews with four residents and four staff members. Additionally, LPA reviewed needs and service plan, physician’s report, care notes, weight record, and incident report pertaining to resident1 (R1). LPA also reviewed facility house rules and menus.
Allegation: Staff do not ensure resident’s dietary needs are met. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that facility staff have offered food items to various residents counter to their dietary needs. It was further revealed through observation that facility staff offers residents in care the same food items while in the dining room.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
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-20260403081111
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: CRYSTAL CREEK SENIOR LIVING
FACILITY NUMBER: 392701576
VISIT DATE: 05/05/2026
NARRATIVE
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Additional staff interview regarding dietary needs also confirmed staff is not consistently adhering to dietary needs. As a result, the preponderance of evidence is met and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Director of Wellness and a copy of this report was provided. LIC 811 and Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260403081111
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: CRYSTAL CREEK SENIOR LIVING
FACILITY NUMBER: 392701576
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2026
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements. (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by:
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Licensee to ensure completed staff training on dietary needs and how these needs pertain to various diet restrictions for residents’ in care. Proof of completed training to submitted to LPA by POC due date.
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Based on interviews conducted, staff are not consistently adhering to various resident dietary needs including diabetic and low salt diets. This poses a potential health and safety risk to residents in care.
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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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
04/03/2026 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20260403081111

FACILITY NAME:CRYSTAL CREEK SENIOR LIVINGFACILITY NUMBER:
392701576
ADMINISTRATOR:ANGELA RINGUFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS ROADTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 72DATE:
05/05/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jennifer AlmendarezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not prevent inappropriate interactions between residents
Staff speak to a resident inappropriately
INVESTIGATION FINDINGS:
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On 5-5-2026 at 11:30am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with Director of Wellness Jennifer Almendarez and explained the purpose of the visit. During this investigation, LPA conducted interviews with four residents and four staff members. Additionally, LPA reviewed needs and service plan, physician’s report, care notes, and incident report pertaining to resident1 (R1). LPA also reviewed facility house rules.

Allegation: Staff do not prevent inappropriate interactions between residents. LPA conducted interviews and record reviews as noted above. Additionally, LPA conducted facility observation on 4-22-2026 and 5-5-2026. Based on interviews and record reviews, it was revealed that on 4-22-2026, LPA observed the beginning of a possible resident altercation in which staff intervened and redirected.

{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260403081111
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: CRYSTAL CREEK SENIOR LIVING
FACILITY NUMBER: 392701576
VISIT DATE: 05/05/2026
NARRATIVE
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Further interviews conducted revealed that although residents may engage in some form of inappropriate interactions within dining room and other areas within the facility, facility staff are available to redirect and prevent further escalations. Additionally, interviews conducted did not reveal any corroborated statements from staff not preventing inappropriate interactions between residents. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff speak to a resident inappropriately. LPA conducted interviews and observations as noted above. Based on interviews conducted, there were no corroborated statements to support the allegation of staff speaking inappropriately to a resident in care. Additionally, LPA did not observe staff speaking in an inappropriate manner to any residents in care. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted with Director of Wellness and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5