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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 09/11/2025
Date Signed: 09/11/2025 01:02:09 PM

Substantiated


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
07/17/2025 and conducted by Evaluator Ellen Lindstrom
COMPLAINT CONTROL NUMBER: 27-AS-20250717131442
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:0CENSUS: DATE:
09/11/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Prithika Singh, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident inappropriately touched another resident.
INVESTIGATION FINDINGS:
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 On 9/11/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived unannounced at the facility to conduct a complaint investigation and deliver complaint findings. The LPA met with the Business Office Manager and explained the purpose of the visit.
Allegation: That resident inappropriately touched another resident.
Licensing Program Analyst (LPA) and Licensing Program Manager (LPM) conducted interviews with eight residents. R1 stated that she has had their private parts groped and that a male resident invited her for a cigarette in a dark corner, showed his private part and asked for a sexual favor. Administrators said they would talk to the resident and it hasn't happened again. R2 stated that a male resident frequently has been seen and reported to management that he inappropriately touches female residents and it keeps happening.
Based on interviews, the above allegation is substantiated. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
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 3
Control Number 27-AS-20250717131442
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
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Administrator stated that she will work with Service Center to come up with a plan that will redirect resident in ways that will keep him separate from female residents. Administrator will submit plan to ellen.lindstrom@dss.ca.gov
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Based on statements made by R1 and R2, more than one resident has been seen inappropriately touching other residents in care. This poses a potential threat to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250717131442
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: 09/11/2025
NARRATIVE
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been met. This facility is hereby cited, per California Code of Regulations (Title 22, Division 6, Chapter 8),on the attached 9099-D.
An exit interview was conducted with the Administrator and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3