306006280-4-10-2024-22-AS-AORZ-D4WMMK-20240503094402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006280
Report Date: 04/10/2024
Date Signed: 04/10/2024 04:11:28 PM

Unfounded

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
04/04/2024 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240404121611

FACILITY NAME:	SHASTA RESIDENTIAL CARE		FACILITY NUMBER:	306006280
ADMINISTRATOR:	DINH, KEVIN DINO		FACILITY TYPE:	740
ADDRESS:	16274 SHASTA ST		TELEPHONE:	(714) 300-4540
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 5	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Jason "Jae" Flake		TIME COMPLETED:	02:42 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Facility refused visitor unjustifiably

INVESTIGATION FINDINGS:

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

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct 10-day inspection visit regarding the allegation listed above. LPA Quiroz was greeted by Caregiver 1 (CG1) and met with Caregiver 2 (CG2) and discussed purpose of today's visit. LPA Quiroz attempted to call Administrator Kevin Dinh with no response or call back.
Regarding the allegation " Facility refused visitor unjustifiably," investigation revealed the following: Interviews conducted with three of four interviewees consisting of staff, resident and witness concluded visitor was not refused entry unjustifiably. Two of three interviewees consisting of staff stated, “Visitor was not refused entry, and they toured the facility on April 4, 2024 around lunch time 12pm.” Interview conducted with witness concluded facility entry was not refused on April 4, 2024.
Therefore based on the preponderance of evidence through interviews and observations conducted by LPA Quiroz, the allegation that the " Facility refused visitor unjustifiably" is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.No deficiencies cited during today's visit. An exit interview was conducted with Caregivers on site, and a copy of report was provided at exit.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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 1