<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701374
Report Date: 07/15/2025
Date Signed: 07/15/2025 12:04:53 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
05/21/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250521091347
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:
07/15/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jagtar SinghTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7-15-2025 at 11:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Licensee/Administrator (S1) Jagtar Singh and explained the purpose of the visit. During this investigation LPA conducted interview with S1 and reviewed admission agreement for resident1 (R1). Additionally, LPA conducted a facility observation as part of this investigation.

Allegation: Illegal eviction. Based on interview and observation, it was revealed that a section of a ceiling in the living room area of the facility became damaged resulting in dust particles and other debris in the room. Interview revealed there were two residents living at the facility at the time including R1 who were sent to the hospital by licensee after the damage occurred for safety reasons.

{Cont. on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 5
Control Number 27-AS-20250521091347
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: 07/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Both residents were transported via ambulance. Further investigation and interview revealed that S1 did not utilize the emergency disaster protocol for temporary placement, and informed conservators to find residents new places to live as there was no intention of accepting residents back, and did not provide a written notice of eviction. Additionally, it was revealed that R1 received a verbal notice of eviction due to renovations in March 2025 without a formal written notice to accompany verbal notice per regulatory requirements.

As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. Civil penalty in the amount of $250 is issued in addition to citation due to repeat violation of Section 87224(a) within a 12-month period. An exit interview was conducted with S1 and a copy of this report was provided. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20250521091347
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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2025
Section Cited
CCR
87224(a)
1
2
3
4
5
6
7
87224(a) Eviction Procedures. (a).The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee is not currently providing care for residents at this time and planning renovations.
Licensee to read regulation 87224 and submit a signed statement of understanding to LPA by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, Licensee verbally expressed notice of eviction after property damage; licensee did not provide a written notice of eviction to R1. This posed a potential health, safety, and resident rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/21/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250521091347

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:
07/15/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jagtar SinghTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with obtaining medical care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7-15-2025 at 11:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Licensee/Administrator (S1) Jagtar Singh and explained the purpose of the visit. During this investigation LPA conducted interviews with S1, S2, and additional witness and reviewed admission agreement, needs and services plan, physician’s report, admissions agreement, medication prescriptions, medical records, and discharge paperwork all pertaining to resident1 (R1).
Allegation: Staff did not assist resident with obtaining medical care. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that R1 resided at facility until approximately the later part of March 2025. Interviews and record review further revealed that during R1’s residency, R1 was treated for a rash locate on backside and buttocks area.

{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250521091347
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: 07/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Record reviews revealed that a prescription for Triamcinolone cream was given on 4-24-2024 to treat an observed rash. Records also reveal that R1 was seen by physician on 6-24-2024 for a check up at which time itchiness and rash were observed and treated. Medication Triamcinolone was increased in strength during this visit. An additional prescription for Triamcinolone was prescribed on 10-25-2024. Record review further indicated R1 was seen by physician on 10-30-2024 for a follow up and noted with Erythema and lesion on multiple parts of body. Medication Temovate was started during this visit.
Interviews conducted revealed R1 was given medication as prescribed. LPA reviewed medication prescription orders as part of documentation review. Additional interviews revealed that on later part of March 2025, R1 discharged from facility, and on or about 5-20-2025 was taken to physician by another party and diagnosed with Herpes 1 and 2. Based on interviews and records review in this investigation, there are no additional corroborated statements or evidence to indicate facility did not assist R1 with obtaining medical treatment for observed rashes during R1’s residency. Furthermore, there is no additional evidence to support the diagnosis of Herpes 1 and 2 occurring as a result of facility not assisting with medical treatment as R1 discharged in March 2025 and diagnosed in May 2025 with the condition.

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/Administrator and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5