507005393-8-27-2023-27-AS-LKIG-CV7SSX-20230830140839

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507005393
Report Date: 08/23/2023
Date Signed: 08/27/2023 02:20:22 PM

Substantiated

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
08/10/2023 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230810121038

FACILITY NAME:	MEMORY LANE MANOR		FACILITY NUMBER:	507005393
ADMINISTRATOR:	HOZAN-FARCAS, CONSUELA		FACILITY TYPE:	740
ADDRESS:	420 CORAL WOOD ROAD		TELEPHONE:	(209) 579-2337
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	5	CENSUS: 0	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Consuela Hozan-Farcas		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Uncleared adult living at the facility.

INVESTIGATION FINDINGS:

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On 08/23/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Kimberly Viarella arrived unannounced to this facility to conduct a complaint visit. LPAs were greeted by Licensee, Consuela Hozan-Farcas and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above.

Current Census was 0. A tour of the facility was conducted. A brief interview with Licensee Hozan-Farcas was conducted.

It was alleged that an uncleared adult was living at the facility. LPA Pascua conducted interviews and reviewed facility. Based on interviews conducted it was learned that this facility is not currently housing any residents at this time since January 2023. It was learned that the Licensee has allowed family members and family friends to reside at the facility while there are no residents in care. It was found that the Licensee has conducted tours of the facility to perspective residents and their families within the last few weeks.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230810121038

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: MEMORY LANE MANOR	FACILITY NUMBER: 507005393
	VISIT DATE: 08/23/2023

NARRATIVE

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Based on facility records, these individuals who are residing at the facility at this time are not fingerprint cleared to be at the facility. Based on observation, LPA conducted a facility tour on 08/15/2023 and 08/23/2023 and observed there were no residents in care at this time. LPA toured 4 resident bedrooms where it was observed that there were beds that were unmade, personal belongings such as adult and children clothing, shoes, blankets, pillows, hygiene products and toys. During both visits, it was observed that there were minors who were being home schooled at the facility. In addition, LPA toured the facility kitchen where it was observed to have canned goods and perishable food supply.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

An immediate civil penalty for $500 is being assessed for the violation of 87355(e)(1).

An exit interview was conducted, a copy of the LIC9099, LIC9099-C, LIC9099-D, and appeals rights was provided to the Licensee at the end of this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230810121038

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: MEMORY LANE MANOR	FACILITY NUMBER: 507005393
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/24/2023 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall provide a statement of acknowlegthat states that they have read regulation 87355(e)(1). Licensee shall have a plan to remove individual from facility and obtain a proper criminal record clearance prior to residing at the facility.
	8 9 10 11 12 13 14	Based on observation, interview, and record review, the Licensee did not comply with the section above by ensuring the the individuals residing at the facility have criminal background checks. This poses an immediate health, safety, and personal rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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