342700184-5-8-2023-59-AS-LMUZ-CRNRFR-20230509125934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700184
Report Date: 05/08/2023
Date Signed: 05/08/2023 12:01:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2023 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20230504090346

FACILITY NAME:	SHEARWATER RESIDENCE		FACILITY NUMBER:	342700184
ADMINISTRATOR:	THOMAS, REBECCA		FACILITY TYPE:	740
ADDRESS:	6526 MAIN AVE		TELEPHONE:	(916) 989-1060
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	16	CENSUS: 13	DATE:	05/08/2023
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Rebecca Thomas		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/08/2023 to do complaint investigation for above allegation. LPA met with administrator, Rebecca Thomas and explained the purpose of the visit. LPA wore the following Personal Protective Equipment (PPE) during today's visit-surgical mask.

The department did facility observations and interview S1 to investigate the complaint. From facility observations and interview, it has been concluded that facility had broken fence to side to the facility from couple of months from last storms but facility was working with different vendors to get the repair done. During department visit on 05/08/23, it has been observed that facility had completed the repair for broken fence and it was properly secured for health and safety of residents in care. Therefore, the above allegation 'Facility is in disrepair ' is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No citations were issued during this visit. Exit interview conducted. Copy of the report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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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