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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601524
Report Date: 01/14/2021
Date Signed: 01/14/2021 03:19:12 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2020 and conducted by Evaluator Bennett Fong
COMPLAINT CONTROL NUMBER: 15-AS-20200114130612
FACILITY NAME:PENNY'S GUEST HOMEFACILITY NUMBER:
075601524
ADMINISTRATOR:JOSEFINA GARDNERFACILITY TYPE:
740
ADDRESS:4181 STOREY LANETELEPHONE:
(925) 349-5834
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 5DATE:
01/14/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Josephina GardnerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
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9
Sexual Abuse
Personal Rights - Verbal Abuse
Qualifications - Staff person not mentally competent
Other - Failure to Report
INVESTIGATION FINDINGS:
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5
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9
10
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13
On 1/14/21, at (time), LPM Jeremy Fong conducted an unannounced complaint visit, meeting with S1. Due to the State's current shelter-in-place order due to COVID, the visit was conducted by telephone.

The Department investigated the above allegations and found that the subject resident provided conflicting information pertaining to the allegation of Sexual Abuse, and no other corroborating information emerged. The RP and subject witness did not witness any verbal abuse and had been provided no detail from the subject resident about what had transpired; no other corroborating information emerged. During interview, the subject witness provided insufficient information to illustrate why the witness believed subject staff person to not be mentally competent. The staff person was interviewed by police and the Department, with no information to suggest that the staff person was mentally compromised. The Licensee reported receiving a call from the local PD requesting subject staff person's personal contact information but was given no information regarding the reason; the PD did not respond to attempts to speak directly with CCLD.

Continued on 809C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
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 15-AS-20200114130612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PENNY'S GUEST HOME
FACILITY NUMBER: 075601524
VISIT DATE: 01/14/2021
NARRATIVE
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The Department has investigated this complaint and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are unsubstantiated.

Exit Interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2