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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507001176
Report Date: 05/14/2026
Date Signed: 05/14/2026 02:44:54 PM

Unsubstantiated


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: 65DATE:
05/14/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:nick gaitherTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained an injury while in care as a result of an un-witnessed fall
Staff did not ensure reporting requirements were followed
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a complaint investigation into the above allegations, met with the administrator Nick Gaither to explain the purpose of the visit.

Resident had a fall with a neck/femur fracture from before admission 2/6/26, however the recent 602, does have elements checked that do not support a resident need related to transferring and they are also noted as "supervised". Discharge documents have indepenedant and amulatory checked on a report from 2/6/26. interviews with the staff doing observation of the resident don't comport with a high fall risk prior to the 2/26/26 fall. Resident was not a monitoring system for the time of the fall, now staff observations and 1:1 walking assistance from a staff 2-3 times a day, staff get trained once a year with inservice(July) about fall type risks/ambulating for care and supervision. Supplemental trainings as needed are provided. Resident reported in interview a weakness in the legs, but overall not concerned with unmet mobility needs as she has staff assistance. Resident did sustain an injury as a result of an unwitnessed fall, its not strongly supported that the fall risk was something known or should have been known to the facility prior to the fall.
continued on c page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
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: 05/14/2026
NARRATIVE
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CCLD was notified on 3/4/26, which would be within 7 days of the initial occurrence. Residents family was notified same day. Both notifications are within the timelines in regulation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

LPA gave guidance that if the needs and services of the client have changed(leg weakness/ ambulation assistance), it is time to get an updated 602 for the client. probably a conversation with the doctor about medical devices, walkers/alarms.

A copy of the report was given to the administrator, no citations were given, an exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3