502700869-12-5-2025-27-AS-LRIS-DP92SD-20251210163858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 12/04/2025
Date Signed: 12/05/2025 08:43:20 AM

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
09/05/2025 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20250905144708

FACILITY NAME:	ORANGEBURG MANOR		FACILITY NUMBER:	502700869
ADMINISTRATOR:	JENNIFER WHITELEY		FACILITY TYPE:	740
ADDRESS:	1248 NELSON AVENUE		TELEPHONE:	(209) 527-2222
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	90	CENSUS: 35	DATE:	12/04/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Stephany Issakhani		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff left resident in soiled diapers/clothing

Staff did not notify authorized representative of incident

Due to lack of supervision, resident is missing a tooth

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 Administrator Stephany Issakhani and explained the reason for the visit. Census: 35

Staff left resident in soiled diapers/clothing - Based on records reviewed, and interviews with staff. Resident (R1) LIC602A states that R1 is slightly incontinent. LPA also reviewed R1’s resident care plan that R1 get’s help with toileting. LPA interviewed staff who stated that they are assigned residents during there work shift that they are responsible for changing. Staff stated that are continuing to ask (Reminders) residents in care to use the restroom are change them. LPA Lund observed no soiled diapers during his visit. LPA Lund reviewed facility job description for Resident Care Technicians which states provide assistance to each residents individual care plan.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

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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Control Number 27-AS-20250905144708

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: 12/04/2025

NARRATIVE

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Based on facility records reviewed and interviews with staff, on the information provided, it was unclear if staff left resident in soiled diapers/clothing, therefore the allegation was deemed UNSUBSTANTIATED.

Staff did not notify authorized representative of incident- Based on records reviewed, and interviews with staff. On 4/24/2025 it was noticed by staff that Resident (R1) was missing a tooth. Resident Care Director Jeanie Gaona observed that R1 was in no pain or discomfort and can still eat. On 4/24/2025 at 10:00 the facility notified daughter via telephone of the incident.

Based on records reviewed and interviews with staff, on the information provided, it was unclear if staff did not notify authorized representative of incident, therefore the allegation was deemed UNSUBSTANTIATED.

Due to lack of supervision, resident is missing a tooth- Based on records reviewed, and interviews with staff. LPA Lund interviewed staff who stated Resident (R1) had no falls and didn’t know how R1 was missing a tooth. Internal Occurrence Report dated 4/24/2025 stated that R1 was missing a tooth and was assessed by Resident Care Director (RCD) Jeanie Gaona. R1 had no visible pain or discomfort and was able to eat. RCD notified R1’s daughter on 4/24/2025 of the incident via telephone.

Based on records reviewed and interviews with staff, on the information provided, it was unclear if due to lack of supervision, resident is missing a tooth, therefore the allegation was deemed UNSUBSTANTIATED.

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

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC9099 (FAS) - (06/04)

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