502700367-5-30-2023-27-AS-KHOS-CT9L92-20230629083248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700367
Report Date: 05/10/2023
Date Signed: 05/30/2023 05:39:20 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
02/17/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230217140234

FACILITY NAME:	DALE COMMONS		FACILITY NUMBER:	502700367
ADMINISTRATOR:	POTTER, LARRY		FACILITY TYPE:	740
ADDRESS:	3900 DALE RD		TELEPHONE:	(209) 526-2053
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	110	CENSUS: 90	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Larry Potter		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 05/10/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who were met by the facility designated Administrator Larry Potter. Brief interview was conducted with the facility designated Administrator at this time.
Current census was 90 residents.
The purpose of this complaint visit was to deliver the findings from this investigation for the allegation above.
Based on a review of the facility records, and documents that were submitted by this facility, it was learned that R1 was in arrears on the basic service fees for approximately three months dating back to 12/2022. The amount of past due basic service fees were in the amount of $15, 230.
As a result of non payment of the monthly basic service fees, it was learned that this facility finally served a 30-day notice to pay the late basic service fees or quit unto R1 on 02/13/2023.
This document was delivered and signed by the facility designated Administrator at that time.
It was learned that a proper 30-day notice was given to the facility resident, R1, at that time notifying R1 of the reason for the notice and R1's course of action and rights related to this notice.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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-20230217140234

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DALE COMMONS	FACILITY NUMBER: 502700367
	VISIT DATE: 05/10/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint. There were no deficiencies observed or cited during today’s complaint visit. Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

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