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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701374
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:27:53 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
09/09/2024 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240909175501
FACILITY NAME:CHEROKEE RETIREMENT HOME INCFACILITY NUMBER:
392701374
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE ROADTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: 10DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Cecilia NunezTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff did not keep the facility free from mold
INVESTIGATION FINDINGS:
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On 9-10-24 at 10:27am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPA met with lead caregiver Cecilia Nunez and explained the purpose of the visit. Administrator Jagtar Singh was made aware of LPA visit and purpose via phone and gave permission for lead caregiver to sign in his absence. During this investigation, LPA conducted facility tour including resident bedrooms, bathrooms, common areas, kitchen and outside of facility. LPA also conducted interviews with two staff members and one resident in care. Additionally, LPA reviewed resources related to mold. Interviews and observations revealed no current musky or other odors commonly associated with mold. Observations did not reveal substances appearing to fit description of mold including any wet, slimy, or greenish substances or spots.

As a result, there is not a preponderance of evidence to conclude this facility currently contains mold. As a result this allegation is UNSUBSTANTIATED. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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-20240909175501
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: CHEROKEE RETIREMENT HOME INC
FACILITY NUMBER: 392701374
VISIT DATE: 09/10/2024
NARRATIVE
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A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with lead caregiver and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2