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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507203017
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:28:07 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
09/18/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20230918165639
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: 94DATE:
01/08/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Administrator Lionel Bazan TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff do not accord privacy to resident(s) in care
Staff handle resident(s) in care in a rough manner
Staff are mismanaging the records regarding residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Assistant Administrator Lionel Bazan and explained the reason for the visit.

Staff do not accord privacy to resident(s) in care- LPA Lund based on interviews with staff, and residents in care. Observation of the medical room does have camera in the room. Residents interviewed stated that they only get injections in medical room and do not get unclothe in the room. Staff interviewed stated that they have never witnessed resident in care unclothe in the medical room.


Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
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-20230918165639
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: 01/08/2024
NARRATIVE
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Based on observation, interviews with clients and staff on the information provided, it was unclear if staff do not accord privacy to resident(s) in care, therefore the allegation was deemed UNSUBSTANTIATED.

Staff handle resident(s) in care in a rough manner- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on facility records review, interviews with staff, and residents in care. Residents interviewed stated that they have not been handled in a rough manner. Staff interviewed stated that they have never witnessed staff handling residents in care in a rough manner. They have had training own how to talk and work with the residents in care. Staff interviewed stated if they were to witness a staff member handle a resident in a rough manner, they would immediately report it to management.

Based on facility records reviewed, interviews with clients and staff on the information provided, it was unclear if staff handle resident(s) in care in a rough manner, therefore the allegation was deemed UNSUBSTANTIATED.

Staff are mismanaging the records regarding residents in care- LPA Lund reviewed facility records and interviewed staff. Based on facility records the facility has a check list or records needed for each staff member that works at the facility. LPA Lund pulled five out of thirty-five to random review. The five reviewed records have the required paperwork for each staff. Staff interviewed stated that they have taken training for first aid and personal rights of residents in care. LPA Lund reviewed five residents files and found to be in compliance.

Based on reviewed facility records and interviewed staff on the information provided, it was unclear if staff are mismanaging the records regarding residents in care, 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: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2