507000307-4-6-2021-27-AS-SRIN-BZYRLZ-20210411130757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 04/06/2021
Date Signed: 04/06/2021 03:09:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/02/2021 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210402160940

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: 30	DATE:	04/06/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Telephone - Administrator Prithika Singh Due to Precautions for COVID-19		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Medication is not being administrated appropriately
Staff yell at residents
Staff fail to meet residents care needs
Staff physically abusive towards resident
Staff not allowing resident access to food service
Staff are not safeguarding resident's property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace contacted Administrator via telephone to conduct a initial 10-day complaint investigation due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the allegations with Administrator.
Allegations:
Medication is not being administrated appropriately
Staff yell at residents
Staff fail to meet residents care needs
Staff physically abusive towards resident
Staff not allowing resident access to food service
Staff are not safeguarding resident's property
The Administrator was advised that at this time the complaint is unfounded because the facility where resident (R1) belongs is a skilled nursing and rehabilitation which is Department of Public Health; therefore the allegations are deemed UNFOUNDED for Community Care Licensing and will be cross reported to Department of Public Health.

An exit interview was conducted with Administrator via telephone and a copy of this report and appeal rights was provided to the Administrator via email and an electronic email read receipt confirms receiving this document. Administrator will send 9099 back via email signed to LPA Wallace.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

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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