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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507203017
Report Date: 01/26/2024
Date Signed: 01/26/2024 05:03:42 PM

Substantiated


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
09/14/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20230914121056
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:
01/26/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Administrator Lionel BazanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff administered a medication the resident has an allergy to

Staff does not ensure facility is free of pests
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 administered a medication the resident has an allergy to- LPA Lund interviewed staff and reviewed Unusual Incident/Injury Report dated 8/31/2023 that Resident (R1) received a medication from another resident. R1 had 1 o1 staff supervision until R1 was sent to Doctors Medical Center. R1 was admitted to Doctors Behavior Health Center.
Based on resident (R1) facility records and interview with reporting party the information provided, it clear that the staff administered a medication the resident has an allergy to therefore the allegation was deemed SUBSTANTIATED.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
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 5
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
09/14/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20230914121056

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:
01/26/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Administrator Lionel BazanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff does not seek medical attention to residents when requested
Staff speaks to residents in an inappropriate manner
Staff does not ensure kitchen drain is kept clean
Facility elevator is in disrepair
INVESTIGATION FINDINGS:
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Staff does not seek medical attention to residents when requested- LPA Lund reviewed facility records, interviewed staff & residents in care. Staff interviewed when residents come to staff and tell them they are not feeling well, staff will take them to the med room and check them out before making a decision to call 911 for help or have staff take them to the Emergency Room. Residents interviewed stated the staff are good at making sure their medical needs are being taken care of and staff will take a client to the med room and check them out to see what the next step will be. LPA Lund interviewed resident (R2) who stated has gotten medical attention when needed.

Based on facility records review, interviews with staff and residents in care the information provided, it was unclear if staff does not seek medical attention to residents when requested therefore the allegation was deemed UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230914121056
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: 01/26/2024
NARRATIVE
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Staff speaks to residents in an inappropriate manner- Based on records review and interviews with staff and clients in care. Staff have training on how to treat residents in care, such as how to work with residents with mental health disorders. Management stated that if staff would speak to a resident inappropriately, they would be fired immediately. The facility has a zero-tolerance policy for personal rights violations. LPA interviewed residents in care who stated the staff treat them with dignity and respect. Staff interviewed have never observed staff disrespect residents in their care and if they had would report it to management immediately.
Based on facility records review, interviews with staff and residents in care the information provided, it was unclear if staff speaks to residents in an inappropriate manner therefore the allegation was deemed UNSUBSTANTIATED.
Staff does not ensure kitchen drain is kept clean- Based interviews with staff and observation. Staff interviewed stated that clean the they have never had any issues with the elevator. Residents interviewed stated that they have never had any issues with the elevator. LPA Lund observed the elevator to be working on 9/20/2023, 10/18/2023, 11/27/2023, 12/6/2023, 12/26/2023 & 1/8/2024.
Based on facility records review, interviews with staff and residents in care the information provided, it was unclear if staff speaks to residents in an inappropriate manner therefore the allegation was deemed UNSUBSTANTIATED.
Facility elevator is in disrepair- Based on records reviewed and interviews with staff, residents and observation. The facility has a permit to operate a Conveyance (Elevator) issued dated was 1/31/2023 from the State of California- Department of Industrial Relations- Division of Occupational Safety & Health. The inspection was on 12/5/2022 and permit expires on 12/5/2023. Staff interviewed stated that they have never had any issues with the elevator. Residents interviewed stated that they have never had any issues with the elevator. LPA Lund observed the elevator to be working on 9/20/2023, 10/18/2023, 11/27/2023, 12/6/2023, 12/26/2023 & 1/8/2024.
Based on facility records review, interviews with staff and residents in care the information provided, it was unclear if staff speaks to residents in an inappropriate manner therefore the allegation was deemed UNSUBSTANTIATED.
An exit interview was conducted, and copies of the report and appeal rights left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230914121056
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: 01/26/2024
NARRATIVE
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Staff does not ensure facility is free of pests-LPA Lund reviewed facility records and interviewed Staff. On 4/8/2023 Allpro Pest Services report states that they treated rooms 107, 108, 109, 110, 111, 112, and 113 for bed bugs. On 9/11/2023 Allpro Pest Services report states that they treated rooms 213, 214, 215, and 216 for bed bugs.

Based on facility records and interviews with staff the information provided, it is clear that staff does not ensure facility is free of pests therefore the allegation was deemed SUBSTANTIATED.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230914121056
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This was not met as evidenced by:
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Licensee stated there will be a health and safety training provided to all facility staff within 24 hours and facility staff sign in sheet and training information will be forwarded to LPA.
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Licensee did not ensure facility staff provided the correct medication as prescribed to R1. This posed an immediate health and safety issue to person's in care.
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Type B
02/09/2024
Section Cited
CCR
80087(a)(1)
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80087(a)(1). Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) The licensee shall take measures to keep the facility free of flies and other insects.
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The facility will review its policy on bed bugs and email LPA Lund.
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This requirement was not met as evidenced by: Facility reports dated 4/8/2023 & 9/11/2023 stated that the facility treated for bed bugs. This posed 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: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5