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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:40:07 PM

Substantiated


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
09/30/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240930172435
FACILITY NAME:ORANGEBURG MANORFACILITY NUMBER:
502700869
ADMINISTRATOR:JENNIFER WHITELYFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:90CENSUS: 35DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
01:30 AM
MET WITH:Jennifer Whitley TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not keep the facility free of cockroaches
INVESTIGATION FINDINGS:
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On 10/01/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Jennifer Whitely and explained the purpose of the visit. The purpose of this visit was to inform the facility and it's representative that a complaint has been filed against it at this time.
Current census was 35. A tour of the facility was conducted. A brief interview with FDA Whitely was conducted.
LPA conducted a tour of the facility, 4 resident bedrooms, and the kitchen. In bedroom 1, LPA observed 1 small brown cockroach on the side of the wall, 2 behind the resident bed, and 1 in the corner of the room. A interview with 3 staff was conducted and it was learned that they have seen or have reported small brown cockroaches to the maintenance director around 2 weeks ago.
Based on the observations made during today's visit, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, appeals rights and a copy of the report was given end the of this visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 3
Control Number 27-AS-20240930172435
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: ORANGEBURG MANOR
FACILITY NUMBER: 502700869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2024
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This is not met as evidenced by:
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Administrator stated a statement of correction shall be sent to the LPA via email by POC date.
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Based on observation and interview, the facility did not ensure that the facility was free of cockroaches. LPA observed 4 small cockroaches in resident room and it was learned through interview that facility staff have seen and reported cockroaches. This poses a potential health,safety and personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
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