342701251-8-20-2026-27-AS-APAA-DY7MC2-20260923092847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701251
Report Date: 08/20/2026
Date Signed: 08/20/2026 03:25:06 PM

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
05/04/2026 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20260504094723

FACILITY NAME:	SIERRA LOMA ASSISTED LIVING		FACILITY NUMBER:	342701251
ADMINISTRATOR:	ILONA CORPUS		FACILITY TYPE:	740
ADDRESS:	3950 ANNADALE LANE		TELEPHONE:	(916) 489-6900
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	94	CENSUS: 76	DATE:	08/20/2026
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Steven Bush		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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1) Lack of supervision resulting in resident sustaining an injury(ries).
2) Staff does not provide safe environment for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to Sierra Loma RCFE on 8/20/26 at 1:30pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Administrator, Steven Bush and together discussed the investigation details.

Based on the interviews conducted and documents reviewed during the investigation process, LPA Gould was unable to corroborate the allegations. LPA conducted interviews with four staff members and two residents (see LIC-811 dated 8/20/26) LPA conducted an interview with the alleged victim (R1) who denied burning themselves or being burned at any point while living at the facility. R1 reported feeling safe at the facility and only complaint was in regards to disagreements with thier roommate. LPA conducted interviews with two caregivers who regularly provide assistance with ADLs for R1 including dressing, bathing, grroming and toileting. Both caregivers denied witnessing any bruising, blistering or rashes on R1's person while assisting with ADLs. Report Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260504094723

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: SIERRA LOMA ASSISTED LIVING	FACILITY NUMBER: 342701251
	VISIT DATE: 08/20/2026

NARRATIVE

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LPA reviewed incident reports regarding R1's hospital admissions and both instances identify other issues as the purpose for the hospital visit including abdominal pain, falls and not being at cognitive baseline.

LPA conducted an interview with R1's roommate (R2). R2 denied witnessing R1 burn themselves and denied R1 made any statements regarding a burn or rash. LPA file review did indicate R1 has regular prescription medications for rash. LPA conducted interview with Two additional staff who also denied any knowledge of burns but did identify R1 being diagnosed with rashes on multiple occasions. LPA reviewed R1's shower schedule which is documented as Tuesday and Friday. R1 confirmed receiving assistance on those days. LPA observed inconsistent diagnoses from hospital as one visit described the purpose for a burn and other report indicated a rash.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

LIC9099 (FAS) - (06/04)

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