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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701696
Report Date: 10/01/2026
Date Signed: 10/01/2026 03:13:13 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
05/06/2026 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20260506143140
FACILITY NAME:COZY SENIOR HOMEFACILITY NUMBER:
342701696
ADMINISTRATOR:PATEL, KETANFACILITY TYPE:
740
ADDRESS:3446 BECERRA WAYTELEPHONE:
(805) 728-0584
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
10/01/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Eviction/Discharge: Staff moved resident without consent from resident or authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to Cozy Senior Home on 10/1/26 at 9:30am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Licensee, Ketan Patel and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA conducted interviews with RP, S1 and S2. LPA attempted to interview A1 but the phone number provided to LPA is no longer working. LPA reviewed former resident files and obtained and reviewed text messages between RP and facility admininstrator. LPA reviewed text messages indicating that former resident may need a higher level of care and that she was sent to the hospital. LPA observed a text messge on 5/6/26 where family of former resident was inquiring where former resident is currently located.
Report Continued on LIC 9099-C.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
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 27-AS-20260506143140
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: COZY SENIOR HOME
FACILITY NUMBER: 342701696
VISIT DATE: 10/01/2026
NARRATIVE
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LPA was not provided any documentation by facility including any eviction notifications for higher level of care presented to either the former resident or their authorized representative. RP interviewed denied participating or contacting any placement agencies. RP was aware that facility contacted placement agency but was not notified that former resident had been relocated.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Eviction/Discharge is substantiated.

The following deficiency 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 home.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260506143140
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: COZY SENIOR HOME
FACILITY NUMBER: 342701696
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2026
Section Cited
CCR
87468.1(b)(1)
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Personal Rights of Residents in All Facilities: (b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. A licensee or facility staff may not take any of the following actions...Deny admission to a facility,
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Licensee has agreed to provide a written plan of correction outlining the process and procedures for the eviction/relocation of a resident to ensure the facility eviction process meets title 22 regulations.
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transfer or refuse to transfer a resident within the facility or to another facility, or discharge or evict a resident from a facility. This requirement was not met as evidenced by former resident was transfered to an unlicensed board and care without the knowlege of former resident's authorized representatives which poses an immediate health, safety and personal rights risk to residents in care.
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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: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3