507000307-1-12-2024-27-AS-KHOS-CZJMGL-20240116083608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 01/12/2024
Date Signed: 01/12/2024 12:33:09 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
10/09/2023 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231009145007

FACILITY NAME:	VINTAGE FAIRE RESIDENTIAL		FACILITY NUMBER:	507000307
ADMINISTRATOR:	PRITHIKA B SINGH		FACILITY TYPE:	740
ADDRESS:	3620-A DALE ROAD		TELEPHONE:	(209) 521-1798
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	49	CENSUS: 38	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Joyce Prasad		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was attacked by another resident

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the above allegations. LPA was greeted by buniess office manager and explained the reason for the visit.

Allegation 1 Resident was attacked by another resident is UNSUBSTANTIATED. Based on information gathered both residents are not able to clearly state what might have happened based on there dignosies and R2 has passed way.

LPA was not able to find the allegation did or did not occur. Due to the information gathered LPA finds allegations to be UNSUBSTANTIATED. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

An exit interview was held and a copy of this report was given.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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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