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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 06/24/2024
Date Signed: 06/24/2024 11:41:13 AM

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
03/18/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240318103436
FACILITY NAME:VINTAGE FAIRE RESIDENTIALFACILITY NUMBER:
507000307
ADMINISTRATOR:PRITHIKA B SINGHFACILITY TYPE:
740
ADDRESS:3620-A DALE ROADTELEPHONE:
(209) 521-1798
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:49CENSUS: 34DATE:
06/24/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Prithika SinghTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not assist resident in a timely manner.
Staff do not adequately supervise memory care residents.
Staff do not provide resident with a safe environment.
INVESTIGATION FINDINGS:
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On 6/24/2024 at approximately 10:00am Licensing Program Analyst (LPA) Jensen arrived at facility to deliver findings in relation to the above listed allegations. LPA Jensen met with Administrator Prithika Singh and explained the purpose of today’s visit.

Staff do not assist resident in a timely manner
During the course of the investigation LPA Jensen made 4 site visits during which the interaction between residents and staff were observed. During all 4 visits staff appeared attentive and no residents with unmet needs were observed. LPA Jensen also tested the call signal system which appeared to be in good working order. LPA Jensen also interviewed 5 residents and a hospice nurse that cares for 2 of the residents and none of the interviewees complained about quality or timeliness of care. Based on site observations, the call signal system being in good repair and 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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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-20240318103436
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: 06/24/2024
NARRATIVE
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Staff do not adequately supervise memory care residents

During the course of the investigation LPA Jensen made 4 site visits during which the interaction between residents and staff were observed. During all 4 visits staff appeared to adequately supervise residents in care. LPA Jensen verified with the Modesto Police Department that there have been no call outs to this location this year for issues with residents. LPA Jensen interviewed 5 residents and a hospice nurse that cares for 2 of the residents and none of the interviewees stated they are aware of an occasion where residents were not adequately supervised. LPA Jensen reviewed 4 resident files and found no documentation to support a lack of supervision. Based on observations, records reviewed and 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.

Staff do not provide resident with a safe environment.



During the course of the investigation LPA Jensen made 4 site visits and no safety hazards were observed. LPA Jensen verified with the Modesto Police Department that there have been no call outs to this location this year. LPA Jensen interviewed 5 residents and a hospice nurse that cares for 2 of the residents and none of the interviewees stated they felt the environment was unsafe. While there may have been an occasion wherein an unsafe environment existed, based on observations, records reviewed and 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.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2