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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275201878
Report Date: 10/23/2024
Date Signed: 10/24/2024 01:49:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20241021092757
FACILITY NAME:GLENDORA GUEST HOMEFACILITY NUMBER:
275201878
ADMINISTRATOR:HONESTO R. FERNANDEZFACILITY TYPE:
735
ADDRESS:1905 GLENDORA WAYTELEPHONE:
(831) 443-8746
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY:6CENSUS: 6DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Licensee Honesto FernandezTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff did not provide supervision as necessary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on October 23,2024 at 04:15 .m. to investigate the above allegations. LPA met with facility Licensee Honesto Fernandez, and explained the purpose for today’s visit.

Regarding the allegation Facility staff did not provide supervision as necessary. The facility Licensee is leaving clients unsupervised while he leaves to pick up food for facility residents. Based on interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Licensee Honesto Fernandez, and a copy of this report along with appeals rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 24-AS-20241021092757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GLENDORA GUEST HOME
FACILITY NUMBER: 275201878
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
85065(a)(b)
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85065 Personnel Requirements
(a) In addition to Section 80065, the following shall apply.(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. The following requirement has not been met as evidenced by:
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Licensee will submit plan to hire additional staff at the facility to provide necessary supervision and submit to LPA by POC date of 10/24/2024.
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Based on interviews conducted the Licensee is leaving facility residents unsupervised, which poses an immediate health, safety, or personal rights risk to residents care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2