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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300612904
Report Date: 08/01/2024
Date Signed: 08/01/2024 09:33:12 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240617115325
FACILITY NAME:ADELINE GUEST HOMEFACILITY NUMBER:
300612904
ADMINISTRATOR:ADELINA MONCERAFACILITY TYPE:
740
ADDRESS:741 N. EAST STREETTELEPHONE:
(714) 996-0568
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:6CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Ariel Santos and Jen JimenezTIME COMPLETED:
09:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff, residents and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff hit resident, the investigation revealed the following: Four out of four staff as well as two out of three residents deny any physical abuse occurring at the facility. All but one resident interviewed deny seeing anyone get hit at the facility. LPA observed residents appeared to be taken care of and no visible bruising observed on any resident. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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