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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507002708
Report Date: 05/17/2023
Date Signed: 05/17/2023 02:10:02 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
01/12/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230112164553
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: 3DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Fernanda Solorzano and Emma ObreroTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Wrongful Eviction.
INVESTIGATION FINDINGS:
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LPA Albert Johnson conducted an unannounced visit to deliver findings on the complaint for the allegation listed above.

Based on records reviewed, interviews with the staff and residents the facility was having issues with R1 following the house rules, borrowing money from other residents and allegedly stealing money from a locked storage containing the residents P&I funds.

The Licensee confronted R1 on the 31st of December about the stolen P&I funds, R1 denied taking the money, however, he stated that he would pay all the money back that he took, repay all the money he borrowed and continued to apologize for not following the house rules.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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-20230112164553
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: 05/17/2023
NARRATIVE
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R1 left the facility on December 30th, 2022, to help fix a family car, he came back and stated he wanted to take some of his clothes and did not return until January 9th, of 2023 and took more clothes. R1 has not returned.

As a result of this investigation, this Department found the allegation 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.

An exit interview was conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2