502700575-10-3-2022-27-AS-KHOS-CKCMDX-20221019093150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700575
Report Date: 10/01/2022
Date Signed: 10/03/2022 08:37:43 AM

Unfounded

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
07/14/2022 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220714150547

FACILITY NAME:	A PRESTIGE LIVING		FACILITY NUMBER:	502700575
ADMINISTRATOR:	PIERRE-JEROME,SIMONE		FACILITY TYPE:	740
ADDRESS:	3208 TEHAMA CT		TELEPHONE:	(209) 284-0075
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 5	DATE:	10/01/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sophia Patterson		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff is not cleared to work at the facility

INVESTIGATION FINDINGS:

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On 10/01/2022, at 9:30am Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility unannounced to follow up on the allegation above. LPA Pascua was greeted by Sophia Patterson and was told to call the Facility Designated Administrator(FDA) to let them know that CCL was present at this time. At 9:35am, LPA Pascua met with FDA, Simone-Pierre Jerome and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings of the allegation above. Current census was 5.
During the course of this investigation, LPA Pascua reviewed facility documents and conducted 3 staff interviews. Based on an interview with FDA, Jerome it was learned that the individual was interviewed and went through the process of a background check in order to work at the facility. Shortly after, FDA, Jerome stated that she recieved a letter that they needed to provide more paperwork in order to clear the background check. FDA, stated that she did not allow the individual at any time to work at the facility until she was cleared by the department. FDA, Jerome stated that they never completed the paperwork and therefore could not come back and work for the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2022

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-20220714150547

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: A PRESTIGE LIVING	FACILITY NUMBER: 502700575
	VISIT DATE: 10/01/2022

NARRATIVE

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3 out of the 3 staff members have worked at the facility for the past year and have not seen the individual work at the facility. 1 out of the 3 staff members stated that they work overnight during the weekends and is primarily the individual who works those shifts. 2 out of the 3 staff members rotate between night and day shifts but are at the facility almost 6 days a week.
LPA Pascua also conducted a file review of the facilities personnel roster and compared it to the LIS roster and observed that the individual was not cleared. LPA Pascua also reviewed staff files and it was shown that the individual did not have a staff file. 3 out of 3 staff members all had record that they have been background cleared through the department based on facility file review.

Based the interviews conducted and records review, This agency has investigated the complaint allegation. 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 was conducted and copy of this report was emailed to Facility Designated Administrator, Simone Pierre-Jerome.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2022

LIC9099 (FAS) - (06/04)

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