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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507001176
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:35:27 PM

Unsubstantiated


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
08/31/2023 and conducted by Evaluator Jason Lund
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230831104000
FACILITY NAME:VALLEY COMFORT #5FACILITY NUMBER:
507001176
ADMINISTRATOR:GAITHER,CHRISTOPHERFACILITY TYPE:
740
ADDRESS:2809 LOU ANN DRIVETELEPHONE:
(209) 544-8676
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:92CENSUS: DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Nick GaitherTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable deaths
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with Administrator Nick Gaither and explained the reason for the visit.

Questionable deaths- The department obtained and reviewed six death certificates, medical records and social worker’s notes. With the information provide through death certificates for residents one through six, medical records and social worker’s notes there was no mention of any neglect or abuse in any of the information provided.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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-20230831104000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: VALLEY COMFORT #5
FACILITY NUMBER: 507001176
VISIT DATE: 10/18/2023
NARRATIVE
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32
Based on review of six death certificates, medical records and social worker’s notes on the information provided, it was unclear if there were questionable deaths, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator Nick Gaither and a copy of report was left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2