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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701338
Report Date: 08/13/2026
Date Signed: 08/13/2026 02:24:42 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
04/28/2026 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260428150655
FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
342701338
ADMINISTRATOR:PARAMO, FERNANDO PAZFACILITY TYPE:
740
ADDRESS:8351 LANCRAFT DR.TELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
08/13/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Fernanado Paz Paramo TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff leave resident seated in wheelchair for extended periods of time
Due to staff neglect, resident developed pressure injuries
Unlawful eviction
INVESTIGATION FINDINGS:
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 On 08/13/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Administrator Fernando Paz Paramo and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is four. A brief interview was conducted with Administrator Paramo.

It was alleged that staff leave residents seated in wheelchairs for extended periods of time. The investigation consisted of interviews with facility staff, residents in care, and outside agencies, as well as record reviews and observations. Administrator Paramo stated that Resident 1 (R1) uses a wheelchair and requires staff assistance with transfers between the bed and wheelchair. Interviews with three out of four resident stated that they are "alaways just sitting" and R2 stated, "I am always sitting here and my wheelchair." Two out of two outside agencies interviewed reported concerns regarding residents remaining seated for extended periods.
CONTINUED LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
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 7
Control Number 27-AS-20260428150655
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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 08/13/2026
NARRATIVE
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Outside Agency 1 (OA1) stated that after leaving the facility with R1 for an appointment and returning approximately seven to eight hours later, OA1 observed the other residents seated in the same locations as when OA1 had left. Outside Agency 2 (OA2), who visits the facility for several hours approximately once a week, reported that residents were typically observed sitting and watching television and that R1 was consistently observed seated in a wheelchair in the living room. Additionally, during LPA Lee's facility visits on 04/30/2026 from approximately 8:25 AM to 11:00 AM, 07/10/2026 from approximately 10:11 AM to 11:22 AM, and during today's visit, residents were observed seated in the living room with limited activity observed during the visits. Based on interviews and observations, there is sufficient evidence to support that residents, including R1 who require staff assistance with transfers, routinely remained seated and seated in their wheelchair for extended periods. Therefore, the preponderance of evidence standard has been met, and the allegation is substantiated.

It was alleged that due to staff neglect a resident developed pressure injuries. This investigation consisted of records reviewed, interviews with staff, residents, and the residents in care and outside agencies. Based on the investigation it was learned that on 04/23/2026, R1 was hospitalized and diagnosed with two unstageable pressure injuries on R1’s coccyx and ischium. Home health care records show that as of 04/13/2026, when home health services began, R1 had no pressure injuries. Moreover, care staff 1 (S1) and Administrator Paramo stated they were unaware of any pressure injuries. Upon admission to home health, R1 was assessed as needing assistance with repositioning. Home health staff provided the facility with instructions on repositioning and directed staff 1 to report any skin breakdown immediately and S1 acknowledged that R1 required assistance to turn in bed and stated that Administrator Paramo helped reposition R1. In contrast, Administrator Paramo reported that R1 could turn themself and did not require repositioning. After being notified of R1’s diagnoses, both S1 and Administrator Paramo attributed the injuries to R1 scratching their own blisters. R1 required assistance with incontinence care, meaning facility staff had direct opportunities to observe R1’s skin condition before the injuries progressed to an unstageable level therefore, based on the evidence, the preponderance of evidence standard is met, and the allegation is substantiated.

It was alleged that staff unlawfully evicted a resident. The investigation consisted of interviews with Administrator Paramo and facility staff, and a review of relevant records.

CONTINUED LIC 9099-C

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20260428150655
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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 08/13/2026
NARRATIVE
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The investigation revealed that R1 was issued a 30-day eviction notice dated 03/17/2026, which stated the reason for eviction as, “level of care is higher and needs more professional care.” However, record review revealed that a pre-appraisal was not completed prior to R1’s admission on 06/24/2023, and there was no Needs and Services Plan in place and on file for R1. Additionally, there was no documented reappraisal or change in R1’s condition demonstrating that R1’s care needs had increased to a level that the facility could no longer meet, including documentation related to R1’s hospital visits. Although the facility cited R1’s increased care needs and need for a higher level of care as the basis for eviction, the facility did not have a documented reappraisal demonstrating a change in R1’s condition or establishing that R1’s needs could no longer be met by the facility. Furthermore, the eviction notice did not include required information, including a relocation evaluation, a list of referral agencies, information regarding R1’s or R1’s legal representative’s right to contact the Department to investigate the reasons for the eviction pursuant to Health and Safety Code Section 1569.35, and the address and telephone number of the local Long-Term Care Ombudsman. Administrator Paramo acknowledged that R1 and R1’s responsible party were not provided a copy of R1’s current service plan because a service plan had never been completed. Based on interviews and record review, sufficient evidence was obtained to corroborate the allegation. Therefore, the preponderance of evidence standard is met, and the allegation that staff unlawfully evicted R1 is substantiated.

At the time of the complaint visit, an immediate civil penalty of $500 was issued, and Administrator Paramo was informed that an additional civil penalty was pending review and may be assessed according to Health and Safety Codes 1569.49(f). Once a civil penalty has been determined, the Department will return at a future date to assess civil penalty. As a result due to staff neglect, a resident developed pressure injuries (serious bodily injury) while in care of the facility.

An exit interview was conducted, and a copy of this LIC 9099 report, LIC 421 IM and appeal rights were provided to the Administrator Paramo. Failure to correct the deficiencies may result in civil penalties.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
04/28/2026 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260428150655

FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
342701338
ADMINISTRATOR:PARAMO, FERNANDO PAZFACILITY TYPE:
740
ADDRESS:8351 LANCRAFT DR.TELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE:CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
08/13/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Fernanado Paz Paramo TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting residents’ incontinent needs
Due to staff neglect, resident developed sepsis
INVESTIGATION FINDINGS:
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On 08/13/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Administrator Fernando Paz Paramo and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is four. A brief interview was conducted with Administrator Paramo.

It was alleged that staff are not meeting residents’ incontinent needs. The investigation consisted of interviews with facility staff, residents in care, outside agencies, as well as a review of relevant records and observations. Administrator Paramo and staff 1 (S1) denied the allegations stating that they checked on the residents every two hours and to see if they need to use the toilet and if their incontinence brief is wet. Interview with four out of four residents who stated that their needs are being met. Interview with three out of three outside agencies did not address any concerns with incontinence odor and the residents’ incontinence needs are not being met.
CONTINUED LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
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 7
Control Number 27-AS-20260428150655
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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 08/13/2026
NARRATIVE
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It was learned that the facility does not document or log when the residents use the toilet or is changed other than that residents are checked every two hours. Moreover, during LPA Lee’s facility visits on 04/30/2026, 07/10/2026 and during today’s visit LPA Lee did not observe any incontinence odor in the facility. Therefore, the preponderance of evidence standard has not been met, and the allegation is unsubstantiated.

It was alleged that due to staff neglect, a resident developed sepsis. This investigation consisted of records reviewed, interviews with staff, the residents in care and outside agencies. It was learned that R1 had multiple hospital visits between March and April 2026 due to fluid-filled blisters associated with bullous pemphigoid. Administrator Paramo and S1 stated that R1’s condition continued to worsen despite prescribed treatment. Both reported that R1 frequently removed bandages and scratched the affected areas despite redirection. Administrator Paramo and S1 believed R1 required a higher level of care, and R1 was issued an eviction notice prior to receiving home health services. R1’s home health Registered Nurse (RN) stated that facility staff were adequately managing R1’s wounds. Although R1’s bandages were sometimes wet during wound care visits, the RN considered this normal and did not believe more frequent bandage changes were necessary. The RN also reported observing no signs of infection. On 04/22/2026, R1 appeared to be at baseline; however, on 04/23/2026, R1 was hospitalized and diagnosed with sepsis. Based on interviews and information obtained, facility staff assisted with R1’s wound care, sought a higher level of care, and provided care consistent with the home health RN’s expectations. Although R1 was subsequently diagnosed with sepsis, there is insufficient evidence to establish that facility staff neglect to provide appropriate care or contribute to R1’s condition. Therefore, the preponderance of evidence standard has not been met, and the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this LIC 9099 report was provided to the Administrator Paramo.

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20260428150655
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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2026
Section Cited
HSC
1569.312(a)
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§1569.312(a) Basic services requirements Type A
(a) Care and supervision as defined in Section

This was not met as evidenced by
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 Administrator will review the regulation cited and provide LPA Lee with a statement of reviewing and understanding the regulation cited. POC due by end of day 8/20/2026 5:00 PM
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Based on records review, observations, and interviews, the Licensee did not ensure R1's basic services and needs were being met. Residents are left seated for seated for extended periods of time. This posed an immediate health and safety risk to R1.
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Type A
08/27/2026
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This was not met as evidenced by
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The Administrator agrees to conduct a basic services training course for all staff through an approved vendor with CCLD. Administrator will email LPA Lee documents used for training,
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Based on records review, observations, and interviews, the Licensee did not ensure R1's basic care and supervision needs were being met which led to R1 developing pressure injuries. This posed an immediate health and safety risk to R1.
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training sign in sheet as well as a statement of reviewing and understanding the regulation cited. POC due by end of day 08/27/2026 5:00 PM


Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20260428150655
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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87224(a)(4)
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87224(a)(4) Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days’ written notice to the residents is required except as otherwise specified in paragraph (5)...

This was not met as evidenced by
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Administrator agrees to ensure review the eviction regulation cited and provide LPA Lee with a statement of reviewing and understanding the regulation cited. POC due by end of day 08/27/2026 5:00 PM

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Based on review and interview records, the licensee did not ensure that a lawful eviction was given to R1. This posed a potential health and safety risk to R1.

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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.
SUPERVISOR'S NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7