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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002885
Report Date: 01/15/2026
Date Signed: 01/15/2026 02:52:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
09/15/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250915082226
FACILITY NAME:ACTING WITH LOVE ASSISTED LIVINGFACILITY NUMBER:
455002885
ADMINISTRATOR:TOMPKINS, TASHAFACILITY TYPE:
740
ADDRESS:2635 SAPPHIRE LANETELEPHONE:
(530) 941-1473
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:12CENSUS: 9DATE:
01/15/2026
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:House Manager Leslie RoseTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure resident had enough liquids, resulting in dehydration.
Staff did not ensure resident's incontinence needs were being met.
INVESTIGATION FINDINGS:
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On 1-15-26, at approximately 2:15 PM, Licensing Program Analyst (LPA), Sarah Benson arrived unannounced at Acting with Love Assisted Living for the purpose of delivering final complaint findings received on 9-15-25. LPA was greeted at the door by House Manager Leslie Rose, and was granted access into the facility.

Interview were conducted and reportes reviewed. LPA requested the following documents staff schedule for August, staff list with telephone numbers, residents admission agreement, care plan, staff care notes, medical records and physican reports.

Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
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 3
Control Number 59-AS-20250915082226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ACTING WITH LOVE ASSISTED LIVING
FACILITY NUMBER: 455002885
VISIT DATE: 01/15/2026
NARRATIVE
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Staff did not ensure residents had enough liquids, resulting in dehydration.

During the interview process, the Administrator reported the resident had a cold with a sore throat. Staff S1 stated R1 didn’t feel well with cold-like symptoms for two days, R1s family told staff, I think she is feeling better she just needs to rest. Staff stated on Friday the behavioral health nurse was in and didn't recommend a hospital visit, she needs rest. Staff stated on Sunday she was more lethargic, when I took her vitals her blood pressure and heart rate was elevated, she didn’t have a fever. Staff stated I called EMS and R1 was taken to the hospital.
Staff stated we offered R1 more options to drink to aid in their refusing to drink. Staff stated we offered Sprite, multiple flavored Gatorade, iv liquid, orange juice and chicken broth. Staff reported we always have drinks within reach of the residents.
During the investigation process LPA Benson observed all residents had a drink within arm’s reach.
Document review revealed that R1 needs reminders to perform all ADL tasks.
During staff interviews it was reported that staff give reminders to drink hourly.

Based on the interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Staff did not ensure residents’ incontinent needs were being met.

During the interview process, Staff reported because R1 had aggressive behavior I would do a two person assist when dressing or addressing incontinent. Staff stated R1 didn’t like to be touched. Staff stated R1 was walking and had a bedside toilet. Staff stated R1 was wearing pull-ups but could get herself to the bathroom, bedside toilet. Staff stated that R1 would mostly at night have incontinence. Staff reported R1 had a call button and bed sensor so staff could assist to the rest room at night. Staff reported R1 moved around the facility well. During interviews it was reported that the facility has a program of scheduled toileting at regular intervals. Staff reported every two hours we help the residents to the toilet. Staff stated from the moment she moved in she had darker urine, orangish. Staff reported the dark colored urine didn’t have a odor. Staff stated when R1 moved in she had a UTI with antibiotics. Staff stated the antibiotics were taken and it cleared up. Staff stated on Thursday R1s daughter was visiting and was notified she wasn’t drinking much. Staff stated R1 wasn’t feeling well so we were offering more fluids.


SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250915082226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ACTING WITH LOVE ASSISTED LIVING
FACILITY NUMBER: 455002885
VISIT DATE: 01/15/2026
NARRATIVE
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Continued from 9099C
Staff did not ensure resident's incontinence needs were being met.

Record review revealed R1 had bladder incontinent but not bowel impaired. It was recorded R1 is forgetful of need to urinate at times. It was reported that R1 needs reminders to perform all ADL tasks. I was reported R1 uses commode at bedside, can have accidents at night. Staff will ensure resident is getting to commode safely and help when needed.

LPA reviewed R1’s LIC602 Physician’s Report which states that R1 is incontinent of bowel and bladder, uses briefs, and is unable to care for their own toileting needs. R1’s Care Tracking Sheet states resident is full assist with all ADLs. Care tracking sheet instructions for toilet: Resident needs help with using the bathroom and transferring to and from wheelchair and toilet. Care Plan instructions: Provide assistance with bathing, dressing, hygiene, provide reminders and assist as needed for incontinence care.

Document review revealed, R1s physician report noted that R1 is continent during the day and incontinent at night.

During the investigation LPA Benson observed that the facility had supplies for incontinent residents. LPA observed none of the residents were soaked or soiled during the visit. LPA observed the bed side toilet in R1s bedroom and R1s bed is about ten feet from the bathroom. Staff stated every two hours we help the residents to the toilet. Staff reported R1 had a call button and bed sensor so staff could assist to the rest room at night.

Based on the interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3