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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701374
Report Date: 06/20/2025
Date Signed: 06/20/2025 02:52:41 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
04/01/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250401093031
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: 0DATE:
06/20/2025
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jagtar SinghTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff are not following regulatory procedures for increasing rates based on level of care changes
INVESTIGATION FINDINGS:
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On 6-20-2025 at 1:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Licensee Jagtar Singh and explained the purpose of the visit. Allegation: Facility staff are not following regulatory procedures for increasing rates based on level of care changes. During this investigation, LPA conducted interviews with three residents in care, two staff members, and two additional witnesses. LPA also reviewed admissions agreement, and a level of increase notice for resident1 (R1).
Based on interviews and record reviews it was determined that on 4-21-2025, Licensee furnished to R1’s responsible person via email a notice reflecting a new rate of $4,000.00 starting “ASAP” to meet R1’s care requirements. A review of R1’s admissions agreement states a basic service rate of $1344.00 and a “rate change” clause which states in part: “Written notice must be provided to the resident and the resident's representative, if any, within two business days of providing service at a new level of care that result in a rate increase. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
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 4
Control Number 27-AS-20250401093031
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: 06/20/2025
NARRATIVE
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The notice must include a detailed explanation of the additional services provided at the new level of care, and must itemize the charges." A review of the emailed notice states various care needs of R1, however, does not state itemized charges to accompany care needs.

As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation issued under Title 22, Health and Safety Codes, Chapter 3.2, and noted on LIC 9099D. An exit interview was conducted with Licensee and a copy of this report was provided. Appeal rights provided. LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250401093031
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2025
Section Cited
CCR
1569.657(a)
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1569.657 Rate increase due to change in level of resident care; notice. (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate…The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement was not met as evidenced by:
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Licensee will read regulation 1569.657(a) and provide a written declaration of understanding to LPA by POC due date.
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 Based on interview and record review, Licensee did not ensure a proper notice for a level of care rate increase to R1 per regulatory requirements. This posed a potential health, safety, and resident rights risk to resident 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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
04/01/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250401093031

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: 0DATE:
06/20/2025
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jagtar SinghTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff made inappropriate comments to resident in care
INVESTIGATION FINDINGS:
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On 6-20-2025 at 1:35pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Licensee Jagtar Singh and explained the purpose of the visit. Allegation: Facility staff made inappropriate comments to resident in care. During this investigation, LPA conducted interviews with three residents in care, two staff members, and two additional witnesses. The above allegation alleged licensee stated to resident1 (R1) to “get out” and “your rent is $4000 and I’m coming back to get the money” in demeaning and threatening tone. Based on interviews conducted, it was determined that although Licensee attempted to raise R1’s rate on or about 4-21-2025, there were no corroborated statements existing to indicate Licensee made inappropriate comments to R1 during this process. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. 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 Licensee and a copy of this report was provided. Appeal rights provided.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4