502700934-7-3-2023-27-AS-KHOS-CTFKAG-20230705074356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700934
Report Date: 06/21/2023
Date Signed: 07/03/2023 10:18:36 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230117111149

FACILITY NAME:	PROVIDENCE HOME OF MODESTO		FACILITY NUMBER:	502700934
ADMINISTRATOR:	JALILIE, MARILYN		FACILITY TYPE:	740
ADDRESS:	670 PARADISE RD		TELEPHONE:	(650) 740-8043
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	15	CENSUS: 3	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jaime Velasquez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff speak inappropriately to residents

Staff harass residents to move

Staff do not ensure residents have a safe and healthful environment by exposing residents to cold air

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unannounced complaint visit made out to this facility on 06/21/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregiver, Jaime Velasquez, and briefly interviewed at this time.
This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Michelle Jangar, to inform her that CCL was present at this time. It was learned that the facility designated Administrator stated that she would at least (2) hours before she would be able to attend the complaint visit with this LPA today. It was decided that all forms and documents would be signed and received by the facility live-in caregiver, Jaime Velasquez, in lieu of the facility designated Administrator.
Current census was 3 residents.
Based on interviews and information gathered throughout the course of this investigation, it was learned that facility personnel, S1, has been very aggressive towards current facility residents when discussing the matter of this facility possibly closing in the near future. It was learned that S1 has repeated reminded facility residents that they would have to move soon or not have a place to live at in the near future.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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-20230117111149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
	VISIT DATE: 06/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was learned that this has been a very stressful and daunting situation for the facility residents since the closure date for this facility is approaching fast but they have been unable to secure a proper placement. It was learned that the manner in which facility staff have spoken to the facility residents has been inappropriate, and disrespectful, and needed to stop.
Based on interviews and information gathered throughout the course of this investigation, it was learned that this facility has been experiencing issues with the heating/cooling units, especially for the wings, of this facility. It was learned that the east and west wings of this facility were unable to use the heater when it was cold outside and will not be able to cool the wings when the temperature starts to climb in the upcoming hot summer months. It was observed that fans were present, and in use, but maintenance of the facility in order to cool and heat to a comfortable range for the facility residents could not be maintained at this time.

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

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility caregiver, Jaime Velasquez, at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230117111149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PROVIDENCE HOME OF MODESTO	FACILITY NUMBER: 502700934
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/28/2023 Section Cited CCR 87468.1	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Facility representative stated that all facility personnel will be trained, for no less than (1) hour in duration, on the training topics of Resident Personal Rights from a vendorized entity. A statement of correction, along with proof of vendorized training, will be completed and submitted into CCL by the
	8 9 10 11 12 13 14	This facility was found to be deficient as evidenced by facility staff talking and treating residents without dignity and respect as this facility was moving towards no longer maintaining an RCFE license.	8 9 10 11 12 13 14	due date.
Type A 06/28/2023 Section Cited CCR 87303(b)(1)(2)	1 2 3 4 5 6 7	A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). (2) The facility shall cool rooms to a comfortable range, between 78 degrees	1 2 3 4 5 6 7	Facility representative stated that the heating/cooling units for this facility will be repaired/replaced as necessary to properly heat/cool this facility within the allowed temperature ranges. A statement of correction, along with proof of repairs/replacement of these units, will be completed and submitted into CCL
	8 9 10 11 12 13 14	F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This facility was deficient as evidenced by the heating/cooling units for this facility were not in good working order at this time.	8 9 10 11 12 13 14	by the due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3