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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 185002039
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:46:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2022 and conducted by Evaluator Misty Valencia
COMPLAINT CONTROL NUMBER: 25-AS-20220218110113
FACILITY NAME:ZAMORA RESIDENCEFACILITY NUMBER:
185002039
ADMINISTRATOR:MOTTS, ALICIAFACILITY TYPE:
735
ADDRESS:406 RUSSELL AVENUETELEPHONE:
(530) 251-8442
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:6CENSUS: 6DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sarah Williams, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Client was spoken to in an inappropriate manner while in care.
INVESTIGATION FINDINGS:
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On 06/08/2022, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegation and met with Sarah Williams, Administrator. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Sarah Williams, Administrator.


continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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 25-AS-20220218110113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ZAMORA RESIDENCE
FACILITY NUMBER: 185002039
VISIT DATE: 06/08/2022
NARRATIVE
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Client was spoken to in an inappropriate manner while in care.

During interviews with Administrator, staff, clients, and records reviewed it was determined that client was spoken to in an inappropriate manner while in care to be un-substantiated. Interviews concluded that staff and clients have never witnessed staff speaking inappropriately to clients. one of five (1/5) staff reports that the allegation was only hearsay and was never witnessed. The preponderance of evidence standard has not been met. The allegation is un-substantiated

The preponderance of evidence standard has not been met. The allegations are Unsubstantiated.



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and copy of report emailed to Administrator.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2