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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200529
Report Date: 09/01/2020
Date Signed: 09/01/2020 12:40:50 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
05/26/2020 and conducted by Evaluator Rolanda Pitcher
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200526154452
FACILITY NAME:PENNY'S GUEST HOMEFACILITY NUMBER:
079200529
ADMINISTRATOR:ANGCLA, EPIFANIAFACILITY TYPE:
740
ADDRESS:1768 CANTRELL CTTELEPHONE:
(925) 286-0424
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
09/01/2020
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Josefina GardnerTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility does not have hot water.
INVESTIGATION FINDINGS:
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On 9/1/20, Licensing Program Analyst (LPA) Rolanda Pitcher contacted Staff/Owner, Josefina Gardner. LPA explained due to the present shelter in place order by the Governor, the complaint finding is being delivered via telephone.

LPA has determined based on the interviews conducted and record review the hot water heater on 6/1/20 was not delivering hot water. However, S1, S2 stated within 2 hours the facility contractor, (W1) arrived to the facility and was able to fix the issue. S1 stated the residents daily living was not impacted.

S1 reports, 5 days later the problem happened and again, W1 promptly arrived and was able to resume hot water. S1 states during the 2nd visit, W1 informed her a new valve was needed and ordered it by mail due to shelter in place by the Governor. And upon arrival replaced the valve during the 3rd visit without further incident.

Report continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
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-20200526154452
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: 079200529
VISIT DATE: 09/01/2020
NARRATIVE
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S1, S2, W1 states the hot water was repaired with 2 hours.

On 6/4/20, LPA conducted interviews and provided facility records pertinent to this investigation. LPA has determined based on interviews conducted including pertinent witness account, there is not enough evidence to prove the facility failed to repair/resume hot water in the facility within sufficient time as to not impede resident care.

Based upon records review and interviews conducted the allegation is unsubstantiated. A finding that an allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


Exit interview was conducted with Josefina Gardner



SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2