502700977-10-18-2023-27-AS-KHOS-CWWPXE-20231024114212

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700977
Report Date: 10/18/2023
Date Signed: 10/18/2023 07:56:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/21/2023 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20230721145433

FACILITY NAME:	MONTCLAIR HOME		FACILITY NUMBER:	502700977
ADMINISTRATOR:	KALU, EKE PATRICK		FACILITY TYPE:	735
ADDRESS:	1413 MONTCLAIR DRIVE		TELEPHONE:	(925) 998-1037
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	4	CENSUS: 3	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Patrick Kalu		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with Administrator Patrick Kalu and explained the reason for the visit.

Resident sustained unexplained injuries while in care-LPA Lund reviewed facility records, interviewed staff, reporting party, and witnesses. LPA Lund observed client (C1) hand. Through interviews C1 did wear a bracelet on C1’s hand that C1 would scratch. The facility attempted to take off the bracelet but C1 would refuse to take it off. When C1 did take off the bracelet C1’s hand healed up. The facility did notify C1’s Service Coordinator through Valley Mountain Regional Center. Through observation and interviews C1 hand looks to be self-inflicted scratch mark.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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-20230721145433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MONTCLAIR HOME	FACILITY NUMBER: 502700977
	VISIT DATE: 10/18/2023

NARRATIVE

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Based on facility records review, interviews with staff, reporting party, witnesses and observation on the information provided, it was unclear if resident sustained unexplained injuries while in care, 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 was conducted with Administrator Patrick Kalu and a copy of report was left.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

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