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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507203017
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:43:56 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
08/03/2021 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20210803141124
FACILITY NAME:MODESTO RESIDENTIAL LIVING CENTER, LLCFACILITY NUMBER:
507203017
ADMINISTRATOR:DENNIS MONTEROSSOFACILITY TYPE:
735
ADDRESS:1932 EVERGREEN AVETELEPHONE:
(209) 530-9300
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:100CENSUS: 93DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrative Assistant Christian Jackson TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Neglect/lack of care and supervision resulted in a resident sexually abusing another resident.
INVESTIGATION FINDINGS:
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LPA Jason Lund arrived at the above facility unannounced to complete a complaint investigation. LPA Lund met with Administrative Assistant Christian Jackson and explained the purpose of today's visit.

During the course of the investigation, through in-house reports from the facility, interviewing staff and clients, the facility had eleven incident reports from 8/3/2020 to 3/22/2021 regarding client (C1) inappropriate behaviors with other clients.

On 8/3/2020 at 1020 hours staff (S1) witnessed C1 giving oral sex to Client (C2) on C2s bed. It appeared that C2 was helpless as though C2 didn’t consent to the actions being done. S1 reported the incident to management and wrote up an in-house report regarding the incident. The facility management failed to report the eleven incidents reports to Community Care Licensing (CCL) or the Local Police Department about C1’s behaviors.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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-20210803141124
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: MODESTO RESIDENTIAL LIVING CENTER, LLC
FACILITY NUMBER: 507203017
VISIT DATE: 10/15/2021
NARRATIVE
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Through the interviews and investigation. The Staff didn’t know or how to handle C1’s behaviors of touching people inappropriately. The facility management failed to do training with Staff on how to properly handle clients with these behaviors and meet the need of their clients in care. The facility failed to care for their vulnerable clients in care at the facility.

You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of C2 care while at the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrative Assistant Christian Jackson was provided a copy of the report along and appeal rights.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210803141124
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: MODESTO RESIDENTIAL LIVING CENTER, LLC
FACILITY NUMBER: 507203017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2021
Section Cited
CCR
80072(a)(2)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Plan of Correction will have training with the care staff on how to deal with clients who high risk behaviors and properly meet the needs of clients in care. Will email a copy to LPA Lund.
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This requirement is not met as evidenced by: Based on interviews and record review, the facility failed to accord a safe, healthful and comfortable accommodations for C2. This violation poses an immediate health, and safety risk to clients in care.
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Type A
10/11/2021
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision (a) The Licensee shall provide care and supervision as necessary to meet the client’s needs. This requirement is not met as evidenced by:
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Plan of Correction will have training with the care staff on how to deal with clients who high risk behaviors and properly meet the needs of clients in care. Will email a copy to LPA Lund.
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Based on interviews and record review, the facility failed to properly train their staff on how to clients with behaviors and to meet the needs of their vulnerable clients. This violation poses an immediate health, and safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3