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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701279
Report Date: 05/16/2024
Date Signed: 05/20/2024 12:59:57 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
03/05/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240305101809
FACILITY NAME:STANFORD CROSSINGS CARE HOMEFACILITY NUMBER:
392701279
ADMINISTRATOR:DAMRICHOB, ORCHIDFACILITY TYPE:
740
ADDRESS:765 TERN DR.TELEPHONE:
(209) 687-8835
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY:6CENSUS: 6DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cecil De LaraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Facility is not allowing resident to have visitors or take telephone calls
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 05/16/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated staff person, Cecil De Lara, who was briefly interviewed at this time.
Current census was 6 residents.
The purpose of this visit was to deliver the findings of this investigation to this facility and it's designated staff person at this time.
Based on interivews conducted during the course of this investigation, it was learned that R1 moved into this facility from the bay area for personal reasons. It was learned that R1 had suffered through several medical conditions which required R1 to maintain rest and reduce the amount of stress on R1's mental and physical state. As a result, it was recommended by R1's attending physician that R1 reduce the amount of exposure to external stressors and situations. It was learned that this limited the amount of visitations and interactions on the telephone for R1.
Based on interviews conducted, this facility was abiding by the recommendations from R1's attending
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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-20240305101809
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: STANFORD CROSSINGS CARE HOME
FACILITY NUMBER: 392701279
VISIT DATE: 05/16/2024
NARRATIVE
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physician, as well as, the rights exercised by R1 himself.
Based on a review of the forms and documents, it was learned that R1 personally penned several letters expressing R1's rights to refuse to speak on the telephone nor interact with certain named individuals. It was learned that there were only a few individuals with whom R1 wanted to interact with or have any contact while residing at this facility.
This facility was respecting the wishes and rights of R1 and supported R1's refusal to speak with certain individuals and R1's Rights to refuse visitation from certain individuals.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at the time of this complaint visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2