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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920216
Report Date: 07/28/2026
Date Signed: 07/28/2026 03:15:14 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, 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
12/12/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20251212165422
FACILITY NAME:ROSE ARBOR VILLAGEFACILITY NUMBER:
345920216
ADMINISTRATOR:KLICK, GREGFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:0CENSUS: DATE:
07/28/2026
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Health and Wellness Director Tammy Alves (HWD) TIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility staff had inappropriate interaction with resident in care.
Facility staff did not provide responsible party with incident report.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hiratsuka, conducted this visit to the facility to deliver final findings regarding a complaint that was received on 12/12/2025. The time frame of the allegations is prior to the complaint received by the department

Today, LPA was able to interview the resident in question. The resident in question stated it was a caregiver working for a caregiver placement agency the facility was using to supplement the facility staff. The resident in question stated they were not uncomfortable with that agency caregiver, didn't feel threatened or unsafe, and felt the issue was a non-issue.

Health and Wellness Director Tammy Alves (HWD) stated she reported the issue to the agency the caregiver was working for and the agency handled the caregiver from there.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
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 2
Control Number 59-AS-20251212165422
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: ROSE ARBOR VILLAGE
FACILITY NUMBER: 345920216
VISIT DATE: 07/28/2026
NARRATIVE
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LPA was informed the responsible party was given a report about the incident via email. Initially the person was using someone else to communicate and the facility staff did not disclose anything to that person.

Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

no deficiencies cited
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2