502701713-10-14-2026-27-AS-NWPN-DYV3LH-20261014182045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701713
Report Date: 10/14/2026
Date Signed: 10/14/2026 06:20:55 PM

Document Has Been Signed on 10/14/2026 06:20 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 CARE		FACILITY NUMBER:	502701713
ADMINISTRATOR/ DIRECTOR:	WHITELEY, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1248 NELSON AVE		TELEPHONE:	(925) 594-1122
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY: 90		CENSUS: 47	DATE:	10/14/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	06:00 PM
MET WITH:	Stephanie Issakhani		TIME VISIT/ INSPECTION COMPLETED:	06:30 PM

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	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct case management to go over the findings of the complaint investigation. LPA met with facility administrator Stephanie Issakhani to explain the purpose of the visit. The department conducted interviews, reviewed documentation, and delivered a report summarized here: the precipitating incident to the complaint investigation, was that on 5/28/26 at approximately lunchtime, a resident,r1, was eating lunch with visitors, when a second resident, r2, assaulted r1 via a punch to the face. As to the allegation that the facillity failed to seek medical attention for the resident r1, record review of photos taken after the incident indicated some swelling and internal bleeding around the nose and face of r1. in interview with the staff(S10, S13), it was learned medical attention provided to r1 was an evaluation by the medtech on shift, an ice pack. There was a claim made by 3 facility staff that hospice evaluation occurred on the day of the incident, but the hospice agency has no record of being contacted by the facility via their dedicated phone line or written report, and hospice nurse staff provided a statement the evaluation was conducted the following day(5/29/26) as part of a routine visit. It is the departments stance that because the injury (internal bleeding around the nose and face) wasn't a part of the hospice care condition for r1, medical evaluation by a third party acting in the scope of their practice would be necessary, usually provided by a immediate call to primary care doctor, send out to emergency medical treatment, or nonemergency medical assessment. The hospice evaluation conducted the next day is not sufficient for the purposes of regulatory requirements for providing timely medical attention. Therefore, this allegation has been SUBSTANTIATED. 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

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As to the allegation that the facility failed to prevent a resident from being assaulted by another resident, it was claimed by 1 witness to the incident that r2 was redirected 3 times by staff of the facility and 1 time by a visitor of a r1. It was learned through record review of R2's needs and services plan that 1:1 care was not identified as a need at the time of this incident. Per interview with the administrator, increasing to 1:1 supervision and care for R1 was raised as an issue with the family without success, and additional supervision would be provided to the best of the staffs ability. In interview 2 staff(S10, S13), characterized R2 as having increased behaviors related to aggression and identified needed additional supervision prior to the incident on 5/28/26. Record review of the internal incident reports showed there was a prior physical altercation incident involving R2 and R3 on 05/23/26. Additional supervision did not make it to an updated needs and services plan for R2 prior to the 05/28/26 incident. However, it is unclear if the incident was a direct response to staffs lack of supervision since there were other parties involved in the redirection which could have escalated the behaviors. The finding was unsubstantiated

The departments report was concluded with the investigation of 2 of 5 allegations of the complaint, with the remaining 3 allegations to be investigated by the LPA. Topics raised as a concern during the investigation will be addressed in a following Case management: reappraisals and reporting requirements.

No citations were given as part of this visit, but applied to the complaint and case management. A copy of the report was read and given to the administrator. Exit interview conducted. Appeal rights were 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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