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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 185002765
Report Date: 07/15/2024
Date Signed: 07/15/2024 11:49:44 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240628095039
FACILITY NAME:ZAMORA RESIDENCE IIFACILITY NUMBER:
185002765
ADMINISTRATOR:MOTTS, ALICIAFACILITY TYPE:
735
ADDRESS:116 SOUTH MESATELEPHONE:
(530) 257-2956
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:6CENSUS: 4DATE:
07/15/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caregiver, Sarah WilliamsTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are financially abusing resident.
INVESTIGATION FINDINGS:
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On July 15, 2024 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Zamora Residence II for the purpose of delivering complaint findings. LPA was greeted at the door by Caregiver, Sarah Williams, and was granted access into the facility.

During the course of the investigation, LPA reviewed facility records, interviewed staff, conducted a collateral interview with the client in care and interviewed the Service Coordinator from the Regional Center.

Complaint alleges Staff are Financially abusing resident. During the course of the investigation, LPA interviewed facility staff and learned that the clients bill is not in past due standing and denies that there are any financial abuse going on. LPA interviewed the Service Coordinator and learned that the Service Coordinator reviewed the last six months of the clients bill and reported no issues or concerns. Furthermore, during a collateral interview with the client, LPA received inconsistent statements regarding the allegation. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
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 59-AS-20240628095039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ZAMORA RESIDENCE II
FACILITY NUMBER: 185002765
VISIT DATE: 07/15/2024
NARRATIVE
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A finding that the complaint allegation of Staff are financially abusing resident is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and emailed to the Licensee due to printer issues.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2