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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700869
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:03:36 PM

Document Has Been Signed on 01/29/2025 01:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ORANGEBURG MANORFACILITY NUMBER:
502700869
ADMINISTRATOR/
DIRECTOR:		JENNIFER WHITELEYFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 90CENSUS: 32DATE:
01/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Administrator Jennifer WhiteleyTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to do a case management visit. LPA Lund met with Administrator Jennifer Whiteley and explained the reason for the visit. Census: 32

LPA Lund was investigating a complaint investigation regarding resident (R1). It was reported to licensing that R1 had multiple falls. 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 didn’t report the falls (Injuries) to licensing as well R1 going to the hospital. The facility failed to fill out an Unusual Incident/Injury Report (LIC624) for R1’s fall on 9/18/2024.

Per California Code of Regulations, Title 22, the following deficiencies, and immediate civil penalty have been issued for repeat violation.

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/29/2025 01:03 PM - It Cannot Be Edited


Created By: Jason Lund On 01/29/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
02/12/2025
Section Cited
CCR
87211(a)(1)(B)

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written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…..
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Administrator Jennifer Whiteley will have training with Staff regarding the deficiency and email LPA Lund the POC.
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This requirement was not met as evidenced by: Community Care Licensing didn’t receive UIR for the incident on 9/18/2024. This poses a potential health, safety or personal rights risk to residents 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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