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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701450
Report Date: 02/10/2025
Date Signed: 02/10/2025 09:14:47 PM

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
11/14/2024 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20241114093243
FACILITY NAME:CASA DE MODESTOFACILITY NUMBER:
502701450
ADMINISTRATOR:ISSAKHANI, STEPHANYFACILITY TYPE:
740
ADDRESS:1745 ELDENA WAYTELEPHONE:
(925) 594-1122
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:160CENSUS: 70DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Stephany IssakhaniTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff forced a resident to sign documents
Staff disposed of resident's bank cards
Staff yelled at a resident in care
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 Administrator Stephany Issakhani. and explained the reason for the visit. Census: 70

Staff forced a resident to sign documents - LPA Lund reviewed facility records, interviewed staff, reporting party, witness and residents in care. Based on records reviewed, interviews with staff, reporting party, and residents in care. Resident (R1) signed Residential Agreement on 9/5/2024 with verbal consent from another family. LPA Lund interviewed R1 who stated that R1 was not forced to sign anything. LPA Lund interviewed staff and witness who stated that R1 willing signed the Residential Agreement on 9/5/2024.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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 2
Control Number 27-AS-20241114093243
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: CASA DE MODESTO
FACILITY NUMBER: 502701450
VISIT DATE: 02/10/2025
NARRATIVE
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Based on reviewed facility records, interviews with staff, reporting party, witness and residents in care, on the information provided, it was unclear if staff forced a resident to sign documents, therefore the allegation was deemed UNSUBSTANTIATED.

Staff disposed of resident's bank cards - LPA Lund reviewed facility records, interviewed staff, reporting party, witness and residents in care. Staff along with verbal consent with another family member, the facility set up automatic payments for Resident (R1) care at the facility.

Based on reviewed facility records, interviewed staff, reporting party, witness and residents in care, on the information provided, it was unclear if staff disposed of resident's bank cards, therefore the allegation was deemed UNSUBSTANTIATED.

Staff yelled at a resident in care – LPA Lund reviewed facility records, interviewed staff, reporting party and residents in care. Staff have had, in-service training (Challenging Behaviors and dementia) along with the initial 6 hour and 40 minutes with Care Academy training on how to work with the residents in care. Staff interviewed stated that they have never seen any staff yell at a resident if so, would notify management immediately. Residents interviewed stated that staff have not ever yelled at them.

Based on reviewed facility records, interviewed staff, reporting party and residents in care, on the information provided, it was unclear if staff yelled at a resident 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 conducted and report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
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