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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507003970
Report Date: 09/17/2026
Date Signed: 09/17/2026 04:33:06 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
02/19/2026 and conducted by Evaluator Noel Wolf Petersen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260219114446
FACILITY NAME:DAVIS GUEST HOME VIFACILITY NUMBER:
507003970
ADMINISTRATOR:HEATHER MCCLOSKYFACILITY TYPE:
740
ADDRESS:1209 CENTRAL AVENUETELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:9CENSUS: 9DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Heather McCloskyTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained excessive weight loss due to staff neglect
INVESTIGATION FINDINGS:
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LPA arrived to the facility unannounced to conclude a complaint investigation into the above allegations. LPA met with Administrator Heather McClosky to explain the purpose of the visit. It was learned in record review of american ambulance service logs, that the client had significant ongoing physical deterioration of weight for a period of months(July 2025 - December 2025). Interview with staff acknowledged that the weight loss was so significant that the residents clothing no longer fit, creating a trip hazard. Additionally, staff during interview described the resident as thin, frail and fragile.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, is being cited on the attached LIC 9099D.The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on § 1569.49 H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
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 4
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
02/19/2026 and conducted by Evaluator Noel Wolf Petersen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260219114446

FACILITY NAME:DAVIS GUEST HOME VIFACILITY NUMBER:
507003970
ADMINISTRATOR:HEATHER MCCLOSKYFACILITY TYPE:
740
ADDRESS:1209 CENTRAL AVENUETELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE:CAZIP CODE:
95351
CAPACITY:9CENSUS: 9DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Heather McCloskyTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident's decline in health
Staff did not notify resident's POA of health decline
INVESTIGATION FINDINGS:
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LPA arrived to the facility unannounced to conclude a complaint investigation into the above allegations. LPA met with Administrator Heather McClosky to explain the purpose of the visit. As to the allegation that staff did not seek timely medical attention for resident's decline in health, record review of r1’s eight evaluations from EMS paramedics leading to six hospitializations from March to December 2025 related to a mix of significant, ongoing concerns(shortness of breath, chest pain/edema) and acute incidents(weakness, fall, flu-like symptoms). Over the course of July to December there were also new health concerns for r1 that had regular monitoring from the pcp doc. R1 had a documented habit of refusing care, even in one instance physically striking a doctor. The LPA’s observation of these facts indicate the facility is likely not defficent in timelyness to seek medical treatment, but fails to follow up on reporting these events as required or modify the care plan as necessary in response.

As to the allegation that Staff did not notify resident's POA of health decline, it was learned in interview with the responsible party, conservator, staff s3 was in contact with regards to the decline in behavior for r1, but would not corroborate the weight loss. Record review of the caregiver notes indicates that the caregiver(cg1) independently noted their own observations of weight loss and physical decline of r1, without intervention by the staff of the facility.

Continued on C. page
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20260219114446
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: DAVIS GUEST HOME VI
FACILITY NUMBER: 507003970
VISIT DATE: 09/17/2026
NARRATIVE
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Per t22 regulation, only the physician and responsible party(conservator) are required to be informed, not the POA. There may have been a point when r1 was considered incapacitated to make their own medical decisions, and the LPA would strongly recommended the POA be contacted at that time, but the determination for incapacity to make medical decisions is outside the purview of the state licensing.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

No citation was issued. the matter of reporting requirements, reappraisals, and informing the conservator of the significant weight loss were addressed in a following case managment, LPA read and left a copy of the report with the administrator. Exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20260219114446
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: DAVIS GUEST HOME VI
FACILITY NUMBER: 507003970
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2026
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement was not met as evidenced by:
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LPA is suggesting: retrain with the goal of staff on care and supervision: knowing how to identify a change in physical, mental, emotional, or social functioning, what rendering appropriate assistance to an unmet need is, what documentation is appropriate/required, and what person/persons need to be informed
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a resident with a documented change in physical(weight loss), mental(increased irritability), social functioning(isolation) was not insuring the changes were documented(no updates to the reapprasial) or brought to the attention of Responsible Party(conservator).

Not following this requirement poses a risk to the residents health, safety, and personal rights of clients 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: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4