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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700641
Report Date: 09/09/2026
Date Signed: 09/09/2026 12:24:04 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2026 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20260615110652
FACILITY NAME:SUMMERFIELD OF ROSEVILLEFACILITY NUMBER:
312700641
ADMINISTRATOR:TORRES, NEALFACILITY TYPE:
740
ADDRESS:110 STERLING COURTTELEPHONE:
(916) 772-6500
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:64CENSUS: 40DATE:
09/09/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Neal Torres, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff do not administer resident’s medication as prescribed.
Staff mishandling residents medication.
Staff discriminating against residents.
Staff do not follow hygiene procedures.
Staff do not provide a safe environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with administrator Neal Torres during today’s inspection.
LPA investigated allegation, “Staff do not administer resident’s medication as prescribed”. Relevant party indicated that there were several medication errors and medications were not given as prescribed. Relevant party gave no specific resident, medication, or details. LPA interviewed Gemma Lopez, Health Care Director, in which she stated there have not been recent medication errors or issues with giving resident medications as prescribed. LPA reviewed 4 random resident medications, comparing the MAR and medication orders with the physical medications available to residents. LPA did not observe any medication errors, and all medications were observed available to residents. LPA interviewed 2 residents in care, and both stated they receive their medications daily and have had no issues getting their prescribed medications. LPA interviewed med tech in which she stated there has not been issues with medications. Due to the information gathered LPA finds allegation to be unfounded.
Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
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 59-AS-20260615110652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641
VISIT DATE: 09/09/2026
NARRATIVE
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LPA investigated allegation, “Staff mishandling residents medication”. Relevant party stated medications have not been administered as prescribed due to personal beliefs or personal opinions taking precedence over physician orders and established care plans. In addition, relevant party stated medications are not always being given correctly, creating potential risks to residents’ health and safety. LPA interviewed Gemma Lopez, Health Care Director, in which she stated there have not been recent medication errors or issues with giving resident medications as prescribed. LPA reviewed 4 random resident medications, comparing the MAR and medication orders with the physical medications available to residents. LPA did not observe any medication errors, and all medications were observed available to residents. LPA interviewed 2 residents in care, and both stated they receive their medications daily and have had no issues getting their prescribed medications. LPA interviewed med tech in which she stated there have been no issues with medications. Due to the information gathered LPA finds allegation to be unfounded.

LPA investigated allegation, “Staff discriminating against residents”. Relevant Party stated there is racial discrimination and unequal treatment toward both staff and residents. Relevant party stated they have witnessed conduct, comments, and actions that appear discriminatory and create a hostile environment for employees and residents. Relevant party gave no specific details or residents. LPA interviewed Gemma Lopez and Administrator Neal Torres in which they stated they are not aware of any incidents of racial discrimination or unequal treatment for residents or staff. LPA interviewed 2 residents in care in which they stated the staff treat them with kindness and have not had any issues with the care staff. LPA interviewed 3 care staff in which they stated they have not observed any incidents of racial discrimination or unequal treatment. Due to the information gathered LPA finds allegations to be unfounded.

Continuation on 9099-C.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20260615110652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641
VISIT DATE: 09/09/2026
NARRATIVE
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LPA investigated allegation, “Staff do not follow hygiene procedures”. Relevant party stated staff do not always adhere to proper hand hygiene, sanitation, personal protective equipment requirements, and other required health and safety procedures, placing residents at risk. Relevant party gave no specific details or staff members. LPA interviewed Gemma Lopez, Health Care director, and she stated training is provided to staff on proper hygiene procedures. Gemma stated she has not observed and nothing has been reported to her that staff are not washing their hands properly or that hygiene procedures are not being followed. LPA interviewed 3 care staff in which they stated they have been given training on proper hygiene procedures and they wash their hands frequently and use gloves during care. Staff stated they have no observed any incidents of other staff not following hygiene procedures. Due to the information gathered, LPA finds allegations to be unfounded.

LPA investigated allegation, “Staff do not provide a safe environment for residents”. Relevant party stated staff members have been subjected to verbal abuse, threats, and other inappropriate behaviors without proper documentation, follow-up, behavior tracking, or implementation of interventions to protect staff and residents. Relevant party stated that this creates an unsafe work environment and may impact on the quality of resident care. Relevant party gave no specific details or specific staff or residents. LPA interviewed Gemma Lopez, health care director, and she is not aware of any incidents that have impacted the residents’ quality of care. LPA interviewed 3 care staff in which they stated there have not been any verbal abuse, threats, or other inappropriate behaviors by staff. LPA interviewed 2 residents in care in which they stated the staff treat them with kindness and provide them with care whenever they are in need. Residents stated they have had no issues with the staff. Due to the information gathered, LPA finds allegations to be unfounded.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.



Exit interview was conducted and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2026 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20260615110652

FACILITY NAME:SUMMERFIELD OF ROSEVILLEFACILITY NUMBER:
312700641
ADMINISTRATOR:TORRES, NEALFACILITY TYPE:
740
ADDRESS:110 STERLING COURTTELEPHONE:
(916) 772-6500
CITY:ROSEVILLESTATE:CAZIP CODE:
95661
CAPACITY:64CENSUS: DATE:
09/09/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Neal Torres, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Insufficient staffing resulting in inadequate care and supervision for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with administrator Neal Torres during today’s inspection.
LPA investigated allegation, “Insufficient staffing resulting in inadequate care and supervision for residents”. Relevant Party stated there are unsafe staffing levels at times, resulting in inadequate supervision, delayed responses to resident needs, and increased risk to resident safety. Relevant party stated staffing levels have not always been sufficient to safely meet the needs of the resident population. Relevant party gave no specific details or resident information. LPA interviewed Gemma Lopez, Health Care Director, in which she stated they have 4 caregivers and 1 medication technician on the floor during the AM and PM shift and 2 caregivers and 1 medication technician on the floor during the NOC shift. Gemma stated they are not short staffed at this time. LPA interviewed administrator in which he stated they are fully staffed at this moment, but as they get more residents they add more staff when needed.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
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 59-AS-20260615110652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641
VISIT DATE: 09/09/2026
NARRATIVE
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LPA interviewed 2 residents in care in which they stated they get timely care when they request it and there seems to be enough staff in the facility. LPA interviewed 4 care staff in which they stated they are responsible to provide care to residents in addition they need to serve food during meals, do the dishes, and clean up the dining room. 1 caregiver stated they are having a hard time meeting the needs of the residents with the current staffing levels. Due to the information gathered, LPA finds allegation to be unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5