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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701278
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:48:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230821145701
FACILITY NAME:CHEROKEE RETIREMENT HOMEFACILITY NUMBER:
392701278
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE RDTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: 11DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maricar BarzagaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff do not allow resident to receive phone calls
INVESTIGATION FINDINGS:
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On 9/19/23 at approximately 2:45 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigatio in to the above listed allegation. LPA Jensen met with care provider Maricar Barzaga and explained the purpose of today's visit. LPA Jensen also spoke to the Licensee by telephone and explained the purpose of today's visit.

During the course of the investigation, LPA Jensen reviewed the resident file for Resident 1 (R1. LPA Jensen also interviewed 2 staff members, 1 responsible party for a resident and 2 residents including the resident that is the subject of this complaint.

All parties interviewed, including the resident that is the subject of this complaint deny any problems with residents getting phone calls. The staff members interviewed state some residents can and do leave the facility unassisted if they receive a phone call while they are out they are given a message but it is the residents choice as to whether they wish to return or acknowledge the call. Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 27-AS-20230821145701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CHEROKEE RETIREMENT HOME
FACILITY NUMBER: 392701278
VISIT DATE: 09/19/2023
NARRATIVE
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Based on the interviews conducted the allegation of "Staff do not allow resident to receive phone calls" is UNSUBSTANTIATED. Although the allegation may have happened, the preponderance of evidence does not prove it.

No citations are being issued as a result of this investigation. An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2