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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 525002810
Report Date: 06/16/2025
Date Signed: 06/16/2025 02:24:46 PM

Substantiated


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
05/05/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20250505105758
FACILITY NAME:TREASUREFACILITY NUMBER:
525002810
ADMINISTRATOR:LEAK, TAMRAFACILITY TYPE:
740
ADDRESS:25353 LEE STTELEPHONE:
(530) 604-2602
CITY:LOS MOLINOSSTATE: CAZIP CODE:
96055
CAPACITY:6CENSUS: 6DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Casey Foster - administratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff don't meet residents' hygiene needs.- SUBSTANTIATED
INVESTIGATION FINDINGS:
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06/16/2025 01:45 PM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with administrator Casey Foster. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the administrator and staff. LPA reviewed the following documents: Admission Agreement, IPP, Physician’s Report, care plan for 1 client, hourly check sheet, daily task sheet, staff schedule for May 2 - 5 2025, staff list with telephone numbers, photograph.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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 3
Control Number 59-AS-20250505105758
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: TREASURE
FACILITY NUMBER: 525002810
VISIT DATE: 06/16/2025
NARRATIVE
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Staff don't meet residents' hygiene needs.- SUBSTANTIATED

It was reported that a resident was found soiled from head to toe with urine and feces.
LPA reviewed Resident 1’s LIC602 Physician’s Report which states that R1 is incontinent.

LPA reviewed R1’s Individual Program Plan which states that R1 requires full assistance in all of their personal care and daily living needs. IPP further states that R1 is frequently incontinent. LPA reviewed the facility’s daily checklist and it is documented on 05/04/2025 6:00 PM to 4:00 AM shift under the item “Check MC MW RD & KLM When starting and leaving your shift.” A staff had initialed this as being completed (in blue ink), but there is a note written in black ink “both MC & MW were soaked x10”. LPA reviewed hourly logs for Resident 1 (R1) for the dates of 05/02/2025 through 05/05/2025. On 05/02/2025 07:40 AM R1 “showered/wet/old BM”. 05/04/2025 05:00 AM “R1 soaked”.

LPA reviewed a photograph that showed R1 standing up wearing a white shirt, the shirt had urine stains that extended to R1’s chest.

Staff interviewed stated they have occasionally found R1 had not been toileted when they came on shift in the morning.

Administrator stated that staff had reported this incident to her and sent her photographs of the incident.

This allegation is substantiated.

Based on interviews, documents and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Casey Foster.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250505105758
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: TREASURE
FACILITY NUMBER: 525002810
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2025
Section Cited
CCR
876259(b(3)
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876259(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
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Licensee agrees to formulate a plan to ensure that all residents are toileted as needed to keep them clean and dry. Licensee shall submit the plan to LPA as proof of correction.
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Based on interviews and document review the facility did not keep 1 of 6 residents clean and dry.
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POC due to LPA by 06/30/2025.
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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: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3