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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507002708
Report Date: 12/07/2022
Date Signed: 12/08/2022 09:34:43 AM

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
10/19/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221019132608
FACILITY NAME:ST. CHARLES MANORFACILITY NUMBER:
507002708
ADMINISTRATOR:WOODRUFF, DORISFACILITY TYPE:
735
ADDRESS:3316 ST. ANN WAYTELEPHONE:
(209) 483-8725
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Oscar DayritTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Personal Rights
Facility staff is not providing a safe environment due to smoking in the bathroom.
INVESTIGATION FINDINGS:
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On 12/07/2022 at 12:30pm, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA Pascua met with House Manager (HM) Oscar Dayrit and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 4.

Allegation: Personal Rights
Based on interviews and the information that was gathered throughout the course of this investigation, all staff and residents who were interviewed denied witnessing or hearing anything related to the allegation. All staff interviewed stated that R1 complained about everything since they were placed at the facility. It was learned that R1 did not disclose issues between them and S1 until S1 and other staff complained to their Service Coordinator.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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-20221019132608
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: ST. CHARLES MANOR
FACILITY NUMBER: 507002708
VISIT DATE: 12/07/2022
NARRATIVE
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Allegation: Facility staff is not providing a safe environment due to smoking in the bathroom.
Based on interviews and the information that was gathered throughout the course of this investigation, S2 denied ever smoking inside the facility. All staff and residents denied witnessing S2 smoking inside the facility. R1 also denied witnessing S2 ever smoking inside the facility bathroom.

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

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2