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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 05/19/2025
Date Signed: 05/19/2025 10:13:25 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
12/20/2024 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20241220081845
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: 28DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Jennifer WhiteleyTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff handeles resident roughly causing brusing
Staff do not ensure resident takes medication
Staff do not clean the faciltiy properly
Residents are not able to eat/drink in the evening after dinner
Staff are forcing residents to get up and dressed at 5 AM
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Executive Director Jennifer Whiteley and explained the reason for the visit. Census: 28

Staff handles resident roughly causing bruising- LPA Lund reviewed facility records, interviewed staff and residents in care. All staff have had training in Observing, Reporting & Documenting. Staff are to report any bruising to management or any incidents that has happened with a resident in care. Residents interviewed stated they staff have not been mistreated or handled in a rough way by staff. Staff interviewed stated if they were to observe staff mistreating a resident in care, they would notify management immediately.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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-20241220081845
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: 05/19/2025
NARRATIVE
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Based on facility records reviewed, interviews with staff and residents in care, on the information provided, it was unclear if staff handles resident roughly causing bruising, therefore the allegation was deemed UNSUBSTANTIATED.

Staff do not ensure resident takes medication- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on review facility training records the facility staff have been trained to ensure residents take their medication as prescribed. Residents interviewed stated that take the medications the facility provide to them. Staff interviewed stated that the give the medication as prescribed to each resident in care.

Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if staff do not ensure resident takes medication, therefore the allegation was deemed UNSUBSTANTIATED.

Staff do not clean the facility properly- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on visits on 12/26/2024, 3/25/2025 & 5/7/2025, LPA Lund observation of the facility was that the facility was clean and in compliance at the time of the visits. LPA Lund reviewed housekeeping daily records of room/common areas that are cleaned on each day. LPA Lund interviewed care staff who if needed will clean any situations that can up when housekeeping is not at the facility. LPA Lund interviewed residents in care who stated that their rooms and bedding are clean by care staff/housekeeping.

Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if staff do not clean the facility properly, therefore the allegation was deemed UNSUBSTANTIATED.

Residents are not able to eat/drink in the evening after dinner- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on facility weekly menu the facility offers evening snacks with drinks to their residents in care. Residents interviewed stated that the facility staff ask if they would like something to drink often. Staff interviewed stated we ask residents in care if they would like something to drink or they can ask us.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241220081845
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: 05/19/2025
NARRATIVE
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Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if residents are not able to eat/drink in the evening after dinner, therefore the allegation was deemed UNSUBSTANTIATED.

Staff are forcing residents to get up and dressed at 5 AM- LPA Lund reviewed facility records, interviewed staff, and residents in care. LPA Lund interviewed residents in care who stated that they wake up when they want. Staff interviewed stated that they help residents in care when they wake up and do not force them to wake up. Breakfast is served at 8:00 am and if a resident is not awake yet the kitchen staff will hold a plate for the residents who are still sleeping.

Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if staff are forcing residents to get up and dressed at 5 AM, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3