392701278-10-25-2023-27-AS-LKIG-CY2LVH-20231129080530

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701278
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:24:30 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
08/11/2023 and conducted by Evaluator Jennifer Fain

COMPLAINT CONTROL NUMBER: 27-AS-20230811081924

FACILITY NAME:	CHEROKEE RETIREMENT HOME		FACILITY NUMBER:	392701278
ADMINISTRATOR:	SINGH, JAGTAR		FACILITY TYPE:	740
ADDRESS:	4124 CHEROKEE RD		TELEPHONE:	(209) 518-1908
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95215
CAPACITY:	15	CENSUS: 11	DATE:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jagtar Singh		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Refund not provided
Food not sufficient

INVESTIGATION FINDINGS:

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On 10/25/23 at approximately 10:00am Licensing Program Analysts (LPAs) Jennifer Fain and Kesha Lewis arrived unannounced to deliver findings for a complaint investigation into the above listed allegations. LPAs met with Jagtar Singh and explained the purpose of the visit.
Allegation #1 Refund not provided
On 7/14/23 Resident 1(R1) moved out of the facility. Administrator states he mailed the refund check, but R1’s daughter states she did not receive it. Administrator advised she could pick up the refund from the facility. The daughter arrived to pick up the refund check but refused to take it due to the $35 stop check fee deducted from the total. On 9/5/23 Administrator sent the full refund check to R1’s payee, Catholic Charities of Modesto. A copy of the cancelled check was received by CCLD on 9/26/23. Based on letter from administrator to Catholic Charities of Modesto, cancelled check, interviews with administrator and payee, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

Unsubstantiated

Estimated Days of Completion: 10

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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Control Number 27-AS-20230811081924

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: CHEROKEE RETIREMENT HOME	FACILITY NUMBER: 392701278
	VISIT DATE: 10/25/2023

NARRATIVE

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Allegation #2 Food not sufficient
On 8/21/23 LPA Fain observed the Administrator arriving with groceries at the facility. LPA interviewed administrator and Staff 1 (S1) both stated that groceries were purchased Mondays and Tuesdays.
On 9/19/23 and 10/25/23 LPA Fain observed the refrigerator, freezers and pantry were stocked well in excess of the regulatory requirement of 2 days of perishables and 7 days of nonperishable.
Based on observation of the refrigerator, freezers and pantry, and interviews with administrator and staff, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

No citations are being issued as a result of this investigation. An exit interview was conducted, and a copy of this report was provided to Cecelia Nunez

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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