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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507203017
Report Date: 12/26/2023
Date Signed: 12/26/2023 03:50:15 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
10/10/2023 and conducted by Evaluator Jason Lund
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231010164801
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: 95DATE:
12/26/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Steven BryantTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident is not provided safe, healthful and comfortable accommodations to meet his/her needs while in care of facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with Administrator Steven Bryant and explained the reason for the visit.

Resident is not provided safe, healthful and comfortable accommodations to meet his/her needs while in care of facility - LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on interviews with staff, and residents in care. Residents (R1) & (R2) interviewed stated that when they found out that their room had bed bugs the facility immediately moved them to another room. R1 & R2 stated that they feel safe at the facility and there needs are being met.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
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-20231010164801
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: MODESTO RESIDENTIAL LIVING CENTER, LLC
FACILITY NUMBER: 507203017
VISIT DATE: 12/26/2023
NARRATIVE
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Based on facility records review, interviews with clients and staff on the information provided, it was unclear if resident is not provided safe, healthful and comfortable accommodations to meet his/her needs while in care of facility, therefore the allegation was deemed UNSUBSTANTIATED.

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

Exit interview conducted and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2