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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005991
Report Date: NO Visit Data Available
Date Signed: 11/22/2023 04:50:48 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231113105418
FACILITY NAME:GARDEN GROVE GUEST HOME LLCFACILITY NUMBER:
306005991
ADMINISTRATOR:TISTOJ, RUTHFACILITY TYPE:
740
ADDRESS:12882 SHACKELFORD LANETELEPHONE:
(714) 638-9470
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:47CENSUS: 38DATE:
UNANNOUNCEDTIME BEGAN:
MET WITH:Ruth Tistoj, AdministratorTIME COMPLETED:
ALLEGATION(S):
1
2
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8
9
Staff stole resident's money.
INVESTIGATION FINDINGS:
1
2
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5
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7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above. LPA was greeted and granted entry by facility staff after explaining the reason for the visit.

An initial complaint investigation visit was conducted on November 15, 2023. LPA requested and obtained records for four residents in care in addition to a list of the current facility employees. LPA accompanied by administrator conducted a tour of the facility's physical plant. Facility administrator also provided LPA with the staff schedule for the month of November including all current facility employees. An interview with administrator was conducted.

CONTINUED ON FORM LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

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

DATE:
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/13/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231113105418

FACILITY NAME:GARDEN GROVE GUEST HOME LLCFACILITY NUMBER:
306005991
ADMINISTRATOR:TISTOJ, RUTHFACILITY TYPE:
740
ADDRESS:12882 SHACKELFORD LANETELEPHONE:
(714) 638-9470
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:47CENSUS: 38DATE:
11/22/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ruth Tistoj, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yelled at residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above. LPA was greeted and granted entry by facility staff after explaining the reason for the visit.

An initial complaint investigation visit was conducted on November 15, 2023. LPA requested and obtained records for four residents in care in addition to a list of the current facility employees. LPA accompanied by administrator conducted a tour of the facility's physical plant. Facility administrator also provided LPA with the staff schedule for the month of November including all current facility employees. An interview with administrator was conducted.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20231113105418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GARDEN GROVE GUEST HOME LLC
FACILITY NUMBER: 306005991
VISIT DATE: 11/22/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099-A
During the present follow-up visit, four resident interviews and four staff interviews were also attempted or conducted.

Regarding the allegation that Staff yelled at residents, the following has been concluded: While it cannot be entirely ruled out that instances of yelling could have happened in the facility, none of the residents or staff members interviewed did corroborate the occurrence. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20231113105418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GARDEN GROVE GUEST HOME LLC
FACILITY NUMBER: 306005991
VISIT DATE: 11/22/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
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30
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32
CONTINUED FROM FORM LIC9099
During the present follow-up visit, four resident interviews and four staff interviews were also attempted or conducted.

Regarding the allegation that Staff stole resident's money, the following has been concluded: Based on interviews with a resident and with the facility administrator, one incident during which $10 in cash were misplaced was identified. While it could not be fully corroborated whether the funds had been recovered, it was however established that it had not been the result of theft conducted by a staff member. Additionally, the facility did not fail to safeguard the cash resources as they had not been entrusted to facility staff in the first place. As a result, the allegation is Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4