507005425-5-6-2024-27-AS-LRIS-D55SXK-20240510141602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507005425
Report Date: 05/06/2024
Date Signed: 05/06/2024 05:31:23 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
01/23/2024 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20240123160938

FACILITY NAME:	PINE MANOR CARE HOME		FACILITY NUMBER:	507005425
ADMINISTRATOR:	KHAN, SAJIDA		FACILITY TYPE:	740
ADDRESS:	1601 SHELDON DRIVE		TELEPHONE:	(209) 524-2878
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	6	CENSUS: 3	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Care Staff Evangeline Majidi		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff with holding resident PN&I based on behavior.

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. LPA Lund met with Care Staff Evangeline Majidi and explained the reason for the visit.

Facility staff with holding resident PN&I based on behavior- Based on records reviewed, interviews with clients, reporting party, witnesses and staff. LPA Lund reviewed PN&I records for clients in care from 9/1/2023 through 1/29/2024 and found no discrepancies for PN&I. LPA Lund interviewed clients in care who stated that facility staff have never withheld any PN&I from them. Staff interviewed have never seen clients not being able to access their PN&I. Witnesses interviewed stated that Client (C1) brings money (PN&I) for activities while C1 is in day program.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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-20240123160938

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: PINE MANOR CARE HOME	FACILITY NUMBER: 507005425
	VISIT DATE: 05/06/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on records review, interviews with clients, reporting party, witnesses and staff the information provided, it was unclear if facility staff with holding resident PN&I based on behavior therefore the allegation was deemed UNSUBSTANTIATED.

The Department (CCLD) has found the allegations. Unsubstantiated.

A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Exit interview was conducted with Administrator Karen Fomby and report left.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2