306000130-10-5-2021-22-AS-SSAS-C9CUYB-20211203145936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000130
Report Date: 10/05/2021
Date Signed: 10/05/2021 01:03:54 PM

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
09/01/2021 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20210901095426

FACILITY NAME:	ANA MARIE'S GUEST HOME		FACILITY NUMBER:	306000130
ADMINISTRATOR:	SHUMAN, ANA M.		FACILITY TYPE:	740
ADDRESS:	1304 E. CHAPMAN		TELEPHONE:	(714) 744-9555
CITY:	ORANGE	STATE: CA	ZIP CODE:	92866
CAPACITY:	6	CENSUS: 5	DATE:	10/05/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Staff Paola Olivares		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff without background clearance working at facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Michelle Reed arrived at the facility to complete this complaint investigation. Upon arrival, LPA met with Staff Paola Olivares and Cesar Acevedo Limon. Licensee Ana Shuman was contacted via telephone. She was not feeling well and could not come to the facility.

Interviews were conducted and records were reviewed. Staff Paola Olivares and Cesar Limon are both fingerprint cleared but are not associated to the facility. LPA reminded Ms. Shuman that all staff need to be fingerprint cleared and associated to the facility.

Based upon records reviewed and interviews conducted the allegation is unsubstantiated, meaning that although the allegation may be valid, there is not a preponderance of the evidence to prove that there are unfingerprinted staff present or work in the facility.

An exit interview was conducted and a copy of this report was provided to Paola Olivares.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

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