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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 05:01:54 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
09/15/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20230915160542
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:
01:00 PM
MET WITH:Assistant Administrator Lionel BazanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not adequately trained

Facility air condition is in disrepair
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 are not adequately trained- LPA Lund reviewed facility paperwork and interviewed staff. LPA Lund reviewed staff’s certificate of completion for first aid. The training was done by Administrator Patricia Calla who has a RN license, there are no records stating Administrator Patricia Calla has received training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
Based on resident (R1) facility records and interview with reporting party the information provided, it clear that the staff are not adequately trained therefore the allegation was deemed SUBSTANTIATED.

Substantiated
Estimated Days of Completion:
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 8
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
09/15/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20230915160542

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:
01:00 PM
MET WITH:Assistant Administrator Lionel BazanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are mismanaging resident medication
Staff do not safeguard residents' personal / confidential information
Facility has mold
Staff do not ensure that residents have clean laundry
Facility staff did not address lice
Resident's food is being withheld by staff
Staff do not safeguard resident's personal items
Staff force residents to work in the facility canteen
Staff inappropriately discipline residents
Staff are wihholding resident mail
Staff do not maintain facility clean, sanitary and free of cross contamination
Night staff do not ensure that resident needs are met
Staff do not ensure that resident clothing is in good condition and free of holes
INVESTIGATION FINDINGS:
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Staff are mismanaging resident medication- LPA Lund reviewed facility records, interviewed staff & residents in care. MEDTECKS get five hours of training and five hours of one-on-one training before able to manage medication for residents in care. LPA Lund interviewed staff who stated that the facility has given them the proper training to give medications to residents in care. LPA Lund interviewed residents in care stated that staff do a great job of giving medications and will come back to residents later if they refuse the medications the first time.
Based on facility records review, interviews with staff and residents in care on the information provided, it was unclear if staff are mismanaging resident medication 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 8
Control Number 27-AS-20230915160542
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 do not safeguard residents' personal / confidential information- LPA Lund observed locked rooms that have staff & residents files, interviewed staff & residents. LPA Lund observed locked offices that have staff & residents files and only staff have keys to those offices. Residents and visitors are not allowed in such office without staff present. Resident interviewed stated that they are not allowed in certain offices without staff being present.

Based on observed locked rooms that have staff & residents files, interviewed staff & residents, on the information provided it was unclear if staff do not safeguard residents' personal / confidential information therefore the allegation was deemed UNSUBSTANTIATED.

Facility has mold- LPA Lund observed the facility kitchen, reviewed facility records and interviewed staff. LPA observed the facility walk in refrigerator to have no mold. Facility kitchen staff food handlers training, refrigerator temperature logs and change procedures to keep the kitchen in compliance. Staff interviewed stated if there was mold in the refrigerator, they would notify management immediately.

Based on observation of the kitchen, records review and interviewed staff and residents in care on the information provided, it was unclear if facility has mold therefore the allegation was deemed UNSUBSTANTIATED.

Staff do not ensure that residents have clean laundry- LPA Lund reviewed facility records, observed laundry, interviewed staff & residents in care. LPA Lund observes residents’ laundry to be clean. Each resident has laundry days for staff to clean their clothes. Staff interviewed stated that we clean the clothes and sheets of each resident once a week or as necessary. If resident is have incontinence it will done on a daily basis or as necessary. Resident’s interviewed stated staff do their laundry and always have clean laundry and will do as necessary if needed.

Based on reviewed facility records, observed laundry, interviewed staff & residents in care, on the information provide it was unclear if staff do not ensure that residents have clean laundry therefore the allegation was deemed UNSUBSTANTIATED.
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 8
Control Number 27-AS-20230915160542
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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Facility staff did not address lice- LPA Lund reviewed facility records, interviewed staff & residents. Staff stated that the facility has not had a case of lice in many years. The facility has procedures if there was a case of lice at the facility. Residents interviewed stated that have not had lice.

Based on reviewed facility records, interviewed staff & residents on the information provided, it was unclear if facility staff did not address lice therefore the allegation was deemed UNSUBSTANTIATED.

Resident's food is being withheld by staff- LPA Lund interviewed staff & residents in care. Staff interviewed stated that they have never seen any staff withheld any food for resident in care, if they were to see it they would notify management immediately. Residents interviewed stated that staff has never withheld any food from them.

Based on interviews with staff and residents in care on the information provided, it was unclear if resident's food is being withheld by staff therefore the allegation was deemed UNSUBSTANTIATED.

Staff do not safeguard resident's personal items- LPA Lund reviewed facility records, interviewed staff & residents. Staff interviewed stated that if a resident was to say some item was missing, the facility would look for it and if not found they would replace the item. Residents interviewed stated that the facility will help them find the item missing or replace it.

Based on facility records review, interviews with staff and residents in care on the information provided, it was unclear if staff do not safeguard resident's personal items therefore the allegation was deemed UNSUBSTANTIATED.









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 8
Control Number 27-AS-20230915160542
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 force residents to work in the facility canteen- LPA Lund interviewed staff & resident. LPA Lund interviewed staff stated that resident (R1) volunteers at the canteen maybe two times a week to get extra tickets to get snacks or cigarettes and we don’t force R1 to work the canteen. LPA Lund interviewed R1 who stated that R1 works at the canteen to get snacks and cigarettes.

Based on interviewed with staff and resident on the information provided, it was unclear if staff force residents to work in the facility canteen therefore the allegation was deemed UNSUBSTANTIATED.

Staff inappropriately discipline residents- 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 inappropriately discipline a resident, 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 disrespecting residents in their care and if they had would report it to management immediately.

Based on records review and interviews with staff and clients in care in care on the information provided, it was unclear if staff inappropriately discipline residents therefore the allegation was deemed UNSUBSTANTIATED.

Staff are withholding resident mail- LPA Lund interviewed staff & residents in care. Staff interviewed stated when the mail or packages comes each day they review the mail and packages and give out the mail to residents. Residents stated that they get their mail each day and never had their mail held by staff.

Based on interviews with staff and residents in care the information provided, it was unclear if staff are withholding resident mail therefore, the allegation was deemed UNSUBSTANTIATED.
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: 5 of 8
Control Number 27-AS-20230915160542
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 do not maintain facility clean, sanitary and free of cross contamination- LPA Lund observed the kitchen and interviewed staff. The kitchen has designated area for the mop and to get the soap for the mop. LPA Lund observed no cross contamination with the mop and other kitchen functions in the kitchen. Staff interviewed stated they only use that area for the mop and nothing else.

Based on observation of the kitchen, and interviews with staff on the information provided, it was unclear if staff do not maintain facility clean, sanitary and free of cross contamination therefore, the allegation was deemed UNSUBSTANTIATED.

Night staff do not ensure that resident needs are met- LPA Lund reviewed facility records, interviewed staff, and residents in care. The facility doesn’t have any clients that need help with their activities of daily living skills, such as bathing, eating and mobility. The staff do reminders to residents in care for bathing but do not help with bathing. Residents interviewed stated that the facility staff have been able to meet their needs at all times. Staff interviewed stated that they had sufficient staffing at night to meet the needs of the residents in care.

Based on records review and interviews with staff and clients in care on the information provided, it was unclear if night staff do not ensure that resident needs are met therefore, the allegation was deemed UNSUBSTANTIATED.

Staff do not ensure that resident clothing is in good condition and free of holes- LPA Lund observation of resident clothing, interviews with staff & residents. LPA Lund observed resident clothing to be sufficient with no holes in the clothing. The facility gets donations for clothing as well the resident can buy their own clothing online or staff will take them to get clothing as necessary. Staff stated residents will come to them when they would like new clothing. Residents stated that facility works with them when they are in need of clothes.

Based on observation of resident clothing, interviews with staff & residents on the information provided, it was unclear if Staff do not ensure that resident clothing is in good condition and free of holes 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: 6 of 8
Control Number 27-AS-20230915160542
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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Facility air condition is in disrepair-LPA Lund reviewed facility records and interviewed staff. Facility records indicated that the facility air conditioning (AC) unit in the upstairs was not working from approximately June 6, 2023, through June 27, 2023. The facility failed to notify Community Care Licensing or LPA Lund that the AC unit was not working.

Based on facility records and interviews with staff the information provided, it is clear that facility air condition is in disrepair 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: 7 of 8
Control Number 27-AS-20230915160542
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(f)
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80075 Health Related Services
(f)Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
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Administrator Patricia Calla will show proof of training by a qualified agencey or have trainigng for staff done.
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This requirement was not met as evidenced by:There are no records stating Administrator Patricia Calla has received training in first aid from persons qualified by agencies.This posed an immediate health and safety risk to residents in care.
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Type B
01/29/2024
Section Cited
HSC
80087(a)(1)
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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 has already fixed the AC.
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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: 8 of 8