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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 01/29/2025
Date Signed: 01/29/2025 09:18:20 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 Jason Lund
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: 32DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Jennifer Whiteley TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident sustained multiple injuries due to lack of care from staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to follow up on a complaint investigation regarding the above allegations. LPA Lund met with Administrator Jennifer Whiteley and explained the reason for the visit. Census: 32
Resident sustained multiple injuries due to lack of care from staff - LPA Lund reviewed facility paperwork, interviewed staff and reporting party. LPA Lund reviewed resident (R1) Physician’s Report (LIC602A) dated 8/8/2024 which stated R1 needed assistance with for bathing, grooming, feeding and toileting needs. LPA Lund reviewed the facility Resident Appraisal (LIC603A) form dated 8/9/2024 states that R1 only needed reminders only for toileting. For bathing and dressing reminders with standby of staff. It was reported to licensing that R1 had multiple falls.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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
VISIT DATE: 01/29/2025
NARRATIVE
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The facility had no notes for the falls and no updated needs and services plan for R1. On 09/18/2024 the staff informed the family that R1 was transported to the Emergency Room (ER). Once at the hospital it was reported the R1 had injuries to R1’s head and neck. The facility Resident Appraisal (LIC603A) form didn’t meet the needs of R1. The facility didn’t report the falls (Injuries) to licensing as well R1 going to the hospital.

Based on reviewed facility paperwork, interviews with staff, and reporting party, the information provided, it clear that resident sustained multiple injuries due to lack of care from staff therefore the allegation was deemed SUBSTANTIATED.



As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

Per California Code of Regulations, Title 22, the following deficiencies, and immediate civil penalty have been issued. The circumstances of this complaint are being evaluated for enhanced civil penalties.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of the resident having serious bodily injury while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Exit interview conducted and report provided. Appeals rights printed.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
CCR
87464(d)
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If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below.
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The facility will go over LIC602's and Needs and services plans to make sure they meet the needs of the residents in care.
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This was not met as evidenced by: Based on review of Resident (R1) Physician’s Report (LIC602A) dated 8/8/2024 which stated R1 needed assistance with for bathing, grooming, feeding and toileting needs & the facilities Resident Appraisal dated 8/9/2024 states that R1 only needed reminders only for toileting. For bathing & dressing reminders with standby of staff. This poses an immediate health and safety risk 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: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3