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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507203017
Report Date: 11/07/2024
Date Signed: 11/07/2024 07:10:55 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
08/07/2024 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20240807091809
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: 85DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Lionel BazanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff stole resident's personal items
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 Lionel Bazan. and explained the reason for the visit. Census: 85
Staff stole resident's personal items - LPA Lund reviewed facility records, interviewed staff, reporting party and residents in care. Based on interviews with staff, reporting party, residents in care, and facility records reviewed. Resident (R1) would get cigarettes from family once to twice a month and would have the management office hold on to cigarettes by the pack. LPA Lund reviewed signed paperwork from 8/3/2024 through 9/5/2024, R1 would sign out cigarettes by the pack when needed. Residents interviewed stated that have never had cigarettes taken from them from staff. Staff interviewed stated that they have never seen staff take cigarettes from residents in care if so would notify management.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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-20240807091809
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: 11/07/2024
NARRATIVE
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Based on facility records review, interviews with staff, reporting party and residents, on the information provided, it was unclear if staff stole resident's personal items, 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: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2