502700367-7-3-2024-27-AS-KHOS-D8QNR4-20240902104055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700367
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:24:10 PM

Unfounded

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
06/25/2024 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20240625151010

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: 93	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Larry Potter		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not safeguarding resident personal items

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/3/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director (ED) Larry Potter and Business Office Manager Christine Mancuso and explained the purpose of today's visit.

During the course of the visit, LPA Jensen interviewed 3 staff members, 2 residents and 1 resident family member. LPA Jensen also reviewed 1 resident file. All staff members interviewed confirmed the laundry policy consists of each resident having a designated laundry day. On the designated laundry day during the day shift, a specific staff member collects the laundry and places it in a mesh bag that contains only one resident's clothing. That bag is tagged and washed in a commerical machine and laundry is returned to the resident's room, typically same day. In the evenings care staff will launder clothing or bedding if there is no fresh change of clothing or fresh linen available. If there is alternative clothing options or bedding the laundry can be bagged and tagged and left by the laundry room for the day staff to clean.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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-20240625151010

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: DALE COMMONS	FACILITY NUMBER: 502700367
	VISIT DATE: 07/03/2024

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

The residents interviewed confirmed the laundry routine to be as stated by staff. During the course of an interview Resident 1 (R1) , he stated that personal clothing items have gone missing. LPA Jensen interviewed the responsible party for R1 who confirmed that sometimes she brings R1's clothing home, launders it and returns it. Staff 1 and staff 2 also confirmed that some minor interventions surrounding laundry service have been implemented in collaboration with the family to provide a safe environment for R1.

All staff and residents gave consistent information regarding the facility policy and procedures for resident laundry service. The laundry service protocol includes measures to keep resident clothing separate and accounted for. Based on staff interviews and an interview with R1's responsible party, R1's clothing is brought home on occasion and brought back at a later date. The resident file record review reveals that R1 could have potential for memory lapse. As a result of the interviews conducted and records reviewed the allegation of "Staff are not safeguarding resident personal items" is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2