331880655-12-20-2021-18-AS-DMUN-CPCVGY-20230224152618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880655
Report Date: 12/20/2021
Date Signed: 12/20/2021 12:50:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2021 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211214124147

FACILITY NAME:	ASSURANCE HOME 2		FACILITY NUMBER:	331880655
ADMINISTRATOR:	ARDEN ZALSOS		FACILITY TYPE:	740
ADDRESS:	670 HIGHLAND DR		TELEPHONE:	(818) 482-4256
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92264
CAPACITY:	6	CENSUS: 3	DATE:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Asuncion Cabasal, Caregiver		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced to investigate the above allegation. LPA identified himself and discussed the purpose of the visit with Caregiver Asuncion Cabasal.

Through interviews with Resident one (R1) and Ms. Cavbasal, it was determined that Client one (C1) had moved out of the facility in August, 2021; and therefore, was not able to be interviewed at the facility. LPA interviewed remaining residents, and through those interviews, was able to determine that the allegation was UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Caregiver Asuncion Cabasal and a copy of this report along with LIC 811, was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

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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