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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700473
Report Date: 12/04/2024
Date Signed: 12/04/2024 10:45:09 AM

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
10/21/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241021161128
FACILITY NAME:MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTECFACILITY NUMBER:
392700473
ADMINISTRATOR:SHERYL BRAVOFACILITY TYPE:
740
ADDRESS:430 NORTH UNION RDTELEPHONE:
(209) 823-0164
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:84CENSUS: 99DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Davina BarkerTIME COMPLETED:
11:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents needs are not being met due to a lack of staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12-04-24, Licensing Program Analyst (LPA) kesha Lewis arrived unannounced to deliver findings for the allegations above. LPA met with interim administrator Davina Barker and explained the purpose of the visit.

Based on records reviewed and interviews with staff the above allegation is found to be unsubstantiated. Records show at least one (1) med tech and three (3) care staff each day on all shifts.

There is not sufficient evidence to prove with a preponderance that the above allegation is valid and therefore, the allegation is determined to be UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.


An exit interview was conducted copy of report given. .
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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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