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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507002396
Report Date: 08/20/2026
Date Signed: 08/20/2026 05:40:08 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
05/27/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260527160042
FACILITY NAME:SAMARITAN VILLAGEFACILITY NUMBER:
507002396
ADMINISTRATOR:RIKKI PEREZCHICAFACILITY TYPE:
740
ADDRESS:7700 FOX ROADTELEPHONE:
(209) 883-3000
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY:277CENSUS: DATE:
08/20/2026
UNANNOUNCEDTIME BEGAN:
04:56 PM
MET WITH:TIME COMPLETED:
05:39 PM
ALLEGATION(S):
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9
Staff does not ensure resident is spoken to in an appropriate manner
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct an investigation into the above allegation. LPA met with rikki perezchica to explain the purpose of the visit.

It was claimed by a annonymous party that a resident was in the care of a staff for 1:1 end of life care when the resident verbally expressed thier displeasure with the staffs ability to provide basic assistance repositioning, changing the channel, and the staff is alleged to have returned with a inapproporite remark and then not providing care to the resident for a durration of the her shift.
LPA interviewed connected parties (staff and residents) to the alleged staff: hca manager, shift lead, medtech coworker on shift, residents under the care of the alleged staff. concensus statement was reached that none but the victim and the alleged staff witnessed the alleged behavior, a concensus was not reached about the likelihood of the alleged staff to speak in a rude manner to the resident.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.A copy of the report was read and given to the administrator. an exit interview was conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
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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