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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 185002765
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:22:43 PM

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
07/11/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240711103135
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:
08/12/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Direct Support Professional (DSP), Jessica GlennTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Uncleared adult visiting clients
Personal Rights
INVESTIGATION FINDINGS:
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On August 12, 2024, at approximately 01:00 PM, 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 Direct Support Professional (DSP), Jessica Glenn 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 clients in care. In addition, LPA toured the facility on July 23, 2024, and made observations.

Complaint alleges Uncleared adult visiting clients. During the course of the investigation, LPA interviewed facility staff which included the alleged staff member and could not corroborate the allegation. LPA learned that the alleged caregivers boyfriend would only drop off food to the alleged staff member. Furthermore, during collateral interviews with the clients in care on July 15, 2024, and July 23, 2024, 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: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
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-20240711103135
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: 08/12/2024
NARRATIVE
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Complaint alleges Personal Rights. During the course of the investigation, LPA conducted interviews with the clients in care on July 15, 2024 and July 23, 2024, and received inconsistent statements as it relates to the allegation. Furthermore, LPA learned that clients are free to consume food. LPA conducted a facility tour on July 23, 2024, and observed sufficient perishable and non-perishable foods located in the kitchen refrigerator.

A finding that the complaint allegations of Uncleared adult visiting clients and Personal Rights are 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 by Direct Support Professional (DSP), Jessica Glenn and emailed to the Licensee, Alicia Motts due to printer issues.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC9099 (FAS) - (06/04)
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