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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701206
Report Date: 06/02/2023
Date Signed: 06/06/2023 03:28:11 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
04/19/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230419113948
FACILITY NAME:GARDENS OF MODESTO, THEFACILITY NUMBER:
502701206
ADMINISTRATOR:PETTAPIECE, THERESAFACILITY TYPE:
740
ADDRESS:2325 ST. PAULS WAYTELEPHONE:
(530) 242-8300
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 36DATE:
06/02/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:T. PettapieceTIME COMPLETED:
01:36 PM
ALLEGATION(S):
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Residents are not receiving care due to lack of care staff.
INVESTIGATION FINDINGS:
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Based on records reviewed and interviews conducted the facility had coverage for staff when they call out on several occasions the facility's Activities Director(AD), Business Operations Manager(BOM), Administrator has covered shifts as well as other staff working overtime to assist in meeting the needs of the residents. This situation requiring BOM, AD and Administrator to assist on the floor was a result of the reported positive COVID staff.

LPA reviewed resident's charting and incidents reports for the targeted time period of the alleged staffing shortage and determined that there was not a higher than normally reported incidents. LPA included in the review of incidents: AWOL'S, Aggressive acts, medication errors and emergency room visits.

LPA was unable to determine if the residents in care did not receive meals on a given day timely or at all. LPA was able to confirm through charting and medication records that the reisdents in care recevied medication and incontinence care.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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-20230419113948
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: GARDENS OF MODESTO, THE
FACILITY NUMBER: 502701206
VISIT DATE: 06/02/2023
NARRATIVE
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Based on information provided through interviews and documentation, The allegation against the facility regarding "Residents not receiving care due to lack of care staff."

The allegation was deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.
No deficiencies cited.

An exit interview was conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
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
04/19/2023 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20230419113948

FACILITY NAME:GARDENS OF MODESTO, THEFACILITY NUMBER:
502701206
ADMINISTRATOR:PETTAPIECE, THERESAFACILITY TYPE:
740
ADDRESS:2325 ST. PAULS WAYTELEPHONE:
(530) 242-8300
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 36DATE:
06/02/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:T. PettapieceTIME COMPLETED:
01:36 PM
ALLEGATION(S):
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Facility is not reporting Covid-19 outbreaks
Facility does not have PPE for Covid-19 outbreaks.
INVESTIGATION FINDINGS:
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Allegation: Facility is not reporting Covid-19 outbreaks

Based on records reviewed the facility reported the outbreak on 4/15/2023, via fax and email which included a line list with both staff and residents reported to the department and Modesto Public Health with the required information requested by the both departments. The allegation is unfounded.

Allegation: Facility does not have PPE for Covid-19 outbreaks.

Based on interviews with staff and photos taken of PPE in front of residents rooms and in the supply area the facility has an adequate supply of PPE. During the Covid call from the department on 4/18/2023, the facility was questioned about PPE and was told that there was not a need for additional supplies at that time of the call on 4/19/23 and 4/20/23. The allegation is unfounded
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3