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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507203017
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:49:27 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-20230914113331
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: 93DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Assistant Lionel Bazan TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility has bed bugs
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 Assistant Lionel Bazan and explained the reason for the visit.
Facility has bed bugs - 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 facility has bed bugs therefore the allegation was deemed SUBSTANTIATED.
As a result of this investigation, this LPA found the allegation 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.Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit.
An exit interview was conducted, and copies of the report and appeal rights left.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 27-AS-20230914113331
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: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
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 reviews 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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
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