507000307-5-10-2024-27-AS-KHOS-D6CHUN-20240618063036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 05/09/2024
Date Signed: 05/10/2024 12:53:39 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
02/28/2024 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20240228102945

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: 34	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Joyce Prasad		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff hit residents
Staff handle residents in a rough manner
Staff curse at residents

INVESTIGATION FINDINGS:

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On 5/9/24 at approximately 10:00am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above listed allegations. LPA Jensen met with Business Office Manager, Joyce Prasad, and explained the purpose of the visit.

LPA Jensen conducted site visits at the facility while engaging with residents and observing staff interacting with residents on no less than 6 seperate occassions. LPA Jensen did not see any evidence of physical or verbal abuse during any site visit.

Allegation 1: Staff hit residents
LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or experienced staff hitting a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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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Control Number 27-AS-20240228102945

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: 507000307
	VISIT DATE: 05/09/2024

NARRATIVE

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Allegation 2: Staff handle residents in a rough manner
LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or experienced staff being rough with a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

Allegation 3: Staff curse at residents
LPA Jensen interviewed a total of 9 staff members, 1 hospice nurse, 1 family member of a resident and 10 residents. All deny having ever witnessed or experienced staff cursing at a resident. 10 of 10 residents interviewed stated they are treated well by staff. Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

No deficiencies were cited. An exit interview was conducted and a copy of this report and appeal rights were provided.

LPA Jensen returned on the morning of 5/10/24 to provide report due to technical difficulties with printer

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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