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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700861
Report Date: 03/13/2024
Date Signed: 03/13/2024 04:56:31 PM

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
11/29/2023 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20231129144221
FACILITY NAME:SED RESIDENTIALFACILITY NUMBER:
502700861
ADMINISTRATOR:SANCHEZ, DAMARIS VIDOTFACILITY TYPE:
735
ADDRESS:1110 CUSTER COURTTELEPHONE:
(209) 248-7480
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:4CENSUS: 4DATE:
03/13/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:TIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to keep resident safe
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/13/2024, at approxiimately 2:15 pm Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced complaint visit. LPA Campbell met with Damaris Sanchez, Administrator and explained the purpose of todays visit.

Over the course of the investigation, interviews were conducted that included facility staff, day program staff, residents and family. LPA Campbell also reviewed hosptial records for R1 and staffing schedules. LPA Campbell visited the facility several times and interviewed R1 twice. Based on the interviews conducted, documents reviewed and observations made, the allegation of "Facility failed to keep resident safe" was found to be unsubstantiated.

Complaint allegation findings of UNSUBSTANTIATED mean although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
No deficiencies issued per Title 22 regulations
Exit Interview. Copy of report provided to facility representative.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
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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