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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701713
Report Date: 10/14/2026
Date Signed: 10/14/2026 06:18:17 PM

Document Has Been Signed on 10/14/2026 06:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PLEASANT VALLEY MEMORY CAREFACILITY NUMBER:
502701713
ADMINISTRATOR/
DIRECTOR:		WHITELEY, JENNIFERFACILITY TYPE:
740
ADDRESS:1248 NELSON AVETELEPHONE:
(925) 594-1122
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 90CENSUS: 47DATE:
10/14/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:12 PM
MET WITH:Stephanie IssakhaniTIME VISIT/
INSPECTION COMPLETED:
05:13 PM
NARRATIVE
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct case management to go over concerns raised related to a complaint investigation. LPA met with facility administrator Stephanie Issakhani to explain the purpose of the visit.

It was learned in a recent report by the department several compliance issues:

Reporting requirements; after a physical altercation incidents between residents R1 and R2 there were internal reports generated, but per administrator interview those reports did not make it to ccld in time with the requirements for T22 notification. LPA gave guidance in general, a suspected physical abuse is sufficient to report, 2 hours for phone notification, 24 hours for written notification. Regarding the incident involving R1 and R2, Ombudsman was notified on 5/29/26. Police were notified 5/28/26, and ccld was notified on June/8/26.

During the course of the investigation, an internal report(Pleasant Valley Memory Care Observations) was provided to the department whereas, R2 had assaulted R3. Per the administrator that situation is reversed and r3 was reportedly hitting r2, and the reporting party was a new employee. NO report was provided to the LTCO, CCL or police. Hospice was notified in both cases.

continued on c page
Liza King
Noel Wolf Petersen
DATE: 10/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PLEASANT VALLEY MEMORY CARE
FACILITY NUMBER: 502701713
VISIT DATE: 10/14/2026
NARRATIVE
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Reappraisals; Record review of the last completed appraisal for r2 was 3/10/26, it has self feeding and is absent of aggression. On 4/3/26 R2 had a medication change to aid with behaviors of aggression. Staff documented from 3/09/26 to 5/28/26 observations of increased aggression by r2 toward staff and residents. R2s apparent needs and services plan should have been updated in the form of a reappraisal in advance of R2's resident to resident physical altercation on 5/28/26.


2 citations were given as part of this visit. A copy of the report was read and given to the administrator. Exit interview conducted. Appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2026 06:18 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 10/14/2026 at 05:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PLEASANT VALLEY MEMORY CARE
FACILITY NUMBER: 502701713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2026
Section Cited
CCR
87463(c)(1-3

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If the licensee observes or is made aware of behavioral expression, as defined in Section 87101, that has caused or may cause harm to the resident or others, the licensee shall document all of the following in the resident’s reappraisal: (1) A description of the behavioral expression. (2) If known, identification of events occurring just prior to the behavioral expression including, but not limited to, interactions with other residents or staff, sudden or recent changes in the physical environment, signs of possible new physical illness or injury (such as fever, cough, urinary urgency, or limping), overstimulation (such as from noise or visitors), or physical sensations a resident may not be able to express verbally that may include, but are not limited to, fatigue, heat, cold, pain, hunger, thirst, boredom, fear, wanting to walk, or need for toileting. (3) Interventions to be implemented to minimize the risks to the health and safety of the resident or others associated with the resident's behavioral expression. The licensee shall use the least restrictive intervention to manage the behavioral expression based on the individual needs of the resident.
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LPA suggest the Adminstrator write the LPA a plan of how to address getting the needs and services plans up to date with greater frequence.
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Not following this requirement is evidinced by: record review of active needs and services plan from 3/10/26, record review of addition to medication for aggressive behaviors 4/03/26, interviews with 2 staff client was expressing agresssive behaviors prior to incident on 5/28/26,
Not following this requirement posed a risk to the clients for health, safety, and personal rights
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Type B
10/21/2026
Section Cited
CCR87211(b)

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Any known, suspected, or alleged abuse of an elder or dependent adult that was allegedly caused by another resident of the facility with dementia diagnosed by a licensed physician and there was no serious bodily injury, shall be reported to the long-term care ombudsman, and the local law enforcement agency as required by Welfare and Institutions Code Section 15630(b)(1).
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LPA suggests the facility do a training to review reporting requirements with the staff, who to report to, the timelines to report in, what qualifies as reportable abuse, the administrator will get the training scheduled before the 10/21/26 and show the lpa a schedule noel.wolfpetersen@dss.ca.gov
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not following this requirement is evidenced by: record review of facility observational notes describing a suspected physical abuse reportable event on 5/23/26,
Not following this requirement posed a risk to the clients in care in regards to health, safety and personal rights.
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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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2026


LIC809 (FAS) - (06/04)
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