507000307-5-2-2023-27-AS-KHOS-CSUQCD-20230616120258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507000307
Report Date: 04/19/2023
Date Signed: 05/02/2023 03:54:44 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
02/27/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230227093924

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: 36	DATE:	04/19/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joyce Prasad		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect resulting in resident's death

Staff did not ensure timely medical care for resident

Staff did not ensure resident was hydrated

Staff did not ensure resident was nourished

INVESTIGATION FINDINGS:

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

Unannounced complaint visit made out to this facility on 04/19/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Business Office Manager Joyce Prasad. This LPA requested that the Business Office Manager go ahead and contact the facility designated Administrator to inform her that CCL was present at this time.
Brief interview was conducted with the Business Office Manager at this time.
Current census was 36 residents.
The purpose of this visit was to deliver the findings for this complaint unto the facility, and its representatives, at this time.
It was learned that there were two separate components of care at this facility address. One section of this facility housed the rehabilitation/skilled nursing portion which provided medical care and higher level needs of care unto the residents.
While the other section consisted of the Assisted Living unit which was licensed and overseen by Community Care Licensing at this time.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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-20230227093924

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VINTAGE FAIRE RESIDENTIAL	FACILITY NUMBER: 507000307
	VISIT DATE: 04/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was learned that resident, R1, was not a resident at the licensed assisted living care portion nor was she ever admitted into this portion of the facility.
Instead, it was learned that R1 was admitted into the rehabilitation/skilled nursing portion of this facility where she received a higher level of care and more medical based needs. This portion was not licensed by Community Care Licensing.
All of the allegations and issues connected with this complaint did not take place at this assisted living portion of the facility address.
This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint.

There were no deficiencies observed or cited during today's complaint visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2