502701602-7-14-2026-27-AS-LKIG-DW6TZN-20260720151038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502701602
Report Date: 07/01/2026
Date Signed: 07/14/2026 03:23:04 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
06/01/2026 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20260601104754

FACILITY NAME:	VINTAGE FAIRE RESIDENTIAL		FACILITY NUMBER:	502701602
ADMINISTRATOR:	SINGH, PRITHIKA BANDHANA		FACILITY TYPE:	740
ADDRESS:	3620-A DALE ROAD		TELEPHONE:	(209) 521-1798
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	49	CENSUS: 48	DATE:	07/01/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jose Ventura		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained injury due to staff neglect

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 07/01/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Jose Ventura, who was interviewed at this time.
Current census was 48 residents.
The purpose of this visit was to deliver the findings from this investigation to this facility, and its representative, at this time.
Based on a review of the forms and documents gathered during the course of this investigation, it was learned that a specific incident took place on 05/26/2026 involving resident R1. It was learned that a facility staff person observed that R1 exited another resident's room with a bump on R1's right forearm. It was learned that staff approached R1 and inquired about the bruise to which R1 stated that they were unaware about the origin of the bruise and could not recall how it came about. It was learned that documentation noted that the responsible party for R1 was notified on that same day about the bruising and a follow up medical visit was scheduled for R1 to undergo an X-ray to rule out any further injuries or possible fracture.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

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-20260601104754

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: VINTAGE FAIRE RESIDENTIAL	FACILITY NUMBER: 502701602
	VISIT DATE: 07/01/2026

NARRATIVE

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Based on a review of the forms and documents gathered during the course of this investigation, it was learned that the follow-up medical visit for the X-Ray was conducted and completed on 06/01/2026 by Welbe Health. The results concluded that there was no medical evidence to support that R1 had sustained any injuries related to a fracture at that time.
Based on interviews that were conducted during the course of this investigation, it was learned that the origin of the bruising sustained by R1 was unknown. It was learned that R1 was diagnosed with dementia, along with a language barrier present, made it more difficult for facility staff to gather a reliable account from R1.
It was learned that R1 initially stated that R1's son was the cause for the bruise. Afterwards, R1 changed R1's statement indicating that R1 had bumped into a wheelchair with their forearm and sustained the bruise in that manner. Later on that same day, it was learned that R1 recanted all of the previous statements and denied any knowledge of how the bruising came about.
It was learned that staff, upon the discovery of the bruising, did take the necessary procedures to seek first aid to reduce any discomfort and pain. In addition, the appropriate notifications were made to upper management and the responsible party for R1 as well.
It was learned that the Unusual Incident Report (UIR) was completed and submitted into CCL by the required time frame for this incident that took place involving R1.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC9099 (FAS) - (06/04)

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