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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 07/17/2025
Date Signed: 07/17/2025 10:54:21 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
03/21/2025 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20250321104709
FACILITY NAME:ORANGEBURG MANORFACILITY NUMBER:
502700869
ADMINISTRATOR:JENNIFER WHITELEYFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:90CENSUS: 27DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Executive Director Jennifer Whiteley TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not prevent resident from harming another resident in care

Staff did not provide adequate supervision to resident in care resulting in falls
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 the Executive Director Jennifer Whiteley and explained the reason for the visit. Census: 27
Staff did not prevent resident from harming another resident in care- Based on records reviewed, and interviews with staff. Resident (R1) moved into the facility on 08/25/2022 and moved out on 10/5/2024. LPA Lund reviewed Unusual Incident/Injury Report dated 6/17/2024 from the facility. On 6/11/2024 R1 was having an episode of increased agitation and began throwing objects in the community day room. Staff were attempting to redirect R1, when R1 went to Resident (R2) and grabbed R2’s left forearm and caused a skin tear on R2. Both residents were immediately separated by staff. First aid was immediately applied to R2. continiued on additional forms.....
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 2
Control Number 27-AS-20250321104709
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: 07/17/2025
NARRATIVE
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The facility notified residents responsible party for both R1 and R2. Both residents were placed on 72-hour alert charting for post altercation observation. The facility notified both residents’ hospice agency’s to see if there was a change in condition. LPA Lund reviewed the 72-hour charting for both residents. The facility staff couldn’t have predicted R1 having an episode in the community day room.

Based on facility records reviewed and interviews with staff, on the information provided, it was unclear if staff did not prevent resident from harming another resident in care, therefore the allegation was deemed UNSUBSTANTIATED.

Staff did not provide adequate supervision to resident in care resulting in falls- Based on records reviewed, interviews with staff, and residents in care. Resident (R1) moved into the facility on 08/25/2022 and moved out on 10/05/2024. LPA Lund reviewed Unusual Incident/Injury Reports dated 02/06/2024 & 6/17/2024. On 1/31/2024 R1 was observed on the floor near R1’s room. R1 had a large skin tear to the left of resident’s forehead. R1 was awake and responding but unable to verbalize what happened. 911 was called immediately, staff held pressure to the injury until EMT’s arrived. R1 was transported to Doctor’s Medal Hospital and treated in the Emergency Room. R1 returned to the facility on the same day. On 1/31/2024 Global Hospice visited R1 and there was no significant change in status. On 6/13/2024 had a large skin tear to the left of resident’s forehead. R1 had a large bump on the left side and laceration present well. R1 was awake and responding appropriately. R1 didn’t know how the injury happened. 911 was called and EMT’s took R1 to Doctors Medical Center. R1 returned to the facility on the same day. On 6/13/2024 Global Hospice visited R1 and there was no significant change in status. LPA Lund reviewed facility staffing schedules from 1/1/2024 through 1/31/2024 and 6/1/2024 through 6/30/2024 and there is no staff ratio for RCFE’s but is consistent with residents in care.

Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if staff did not provide adequate supervision to resident in care resulting in falls, 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 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: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
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