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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507001176
Report Date: 07/08/2026
Date Signed: 07/08/2026 06:09:18 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
02/27/2026 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20260227144413
FACILITY NAME:VALLEY COMFORT #5FACILITY NUMBER:
507001176
ADMINISTRATOR:NICK GAITHERFACILITY TYPE:
740
ADDRESS:2809 LOU ANN DRIVETELEPHONE:
(209) 544-8676
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:92CENSUS: 68DATE:
07/08/2026
UNANNOUNCEDTIME BEGAN:
04:34 PM
MET WITH:Nick gaitherTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff did not ensure medical treatment was provided to resident in a timely manner
INVESTIGATION FINDINGS:
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**This report is a copy of the previous report, but with attached D-Page.**

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to deliver findings of a complaint investigation, LPA Met with Administrator (ADM) Nick Gaither to explain the purpose of the visit.

During the investigation LPA conducted interviews and reviewed hospital records and R1s facility file. Interview with S1 and the ADM revealed that on 2/26/26 R1had an unwitnessed fall and was discovered on the ground with a laceration on the cheek. According to interview with S1, they contacted the Responsible Party whom is identified by the faclility as having Durable Power for medical decisions (DPoA) whom refused the facilities suggestion to seek medical assessment such as calling 911. On 02/27/26 per the Unusual Incident Report submitted to CCL, and interview with S2, S2 and the administrator chose to send the R1 out for evaluation of the previous day's injury in response to a complaint of pain by R1. R1s LIC602 documents resident is unable to make needs known. Interview with the Reporting Party revealed that suture care would have been applied if R1 had come in to the hospital the previous day.

Continued on c Page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
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-20260227144413
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: VALLEY COMFORT #5
FACILITY NUMBER: 507001176
VISIT DATE: 07/08/2026
NARRATIVE
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**This report is a copy of the previous report, but with attached D-Page.**

Additionally in record review of the DPOA agreement from the time of the incident, the DPoA was not signed by a doctor indicating it was active. DPOA should not be presumed active, and needs a doctors written order following an assessment of the client to become active. PIN 25-07ASC AUTHORITY OF CONSERVATORS AND AGENTS UNDER POWERS OF ATTORNEY RELATED TO CLIENTS’ RIGHTS and PIN 25-06 ASC CALLING 9-1-1 IN RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) were provided during todays visit as reference.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations is being cited on the seperately attached 9099, LIC 9099D.

Licensee expressed that the is a Dr's Note that would explain the DPOA being estaablished, and that the facility did act appropriately in supplying timely medical attention, such as with offering medical transport assistance, and were it not for the DPOA's resistance to the care, would have reached an outcome where timely medical attention was delivered.

A copy of the report was read and given to the administrator, a copy of the appeal rights were provided. an exit interview conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260227144413
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: VALLEY COMFORT #5
FACILITY NUMBER: 507001176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2026
Section Cited
CCR
87645(a)(1,2)
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87465 Incidental Medical and Dental Care

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.

This requirement was not followed as evidenced by:
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No Immedate, POC. Licensee will put the 2 pins on quaterly staff training for communicating the need for send out for evaluation/radiology to the family, that will be taking place in two weeks. 7/22/26
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Based record review and interviews with administrator and 1 staff that the presumed DPOA refused ER services for the client, and the facility sought medical attention the following day when R1 complained of pain.

Not following this requirement poses an immediate risk to the health and safey and personal rights of a client 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: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3