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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700266
Report Date: 07/19/2024
Date Signed: 07/22/2024 08:08:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240515152858
FACILITY NAME:CABRERA'S GUEST HOMEFACILITY NUMBER:
342700266
ADMINISTRATOR:CABRERA, DIGNAFACILITY TYPE:
735
ADDRESS:1229 SOUTH HARRISON STTELEPHONE:
(209) 598-7588
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: 4DATE:
07/19/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:CABRERA, DIGNATIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Care staff threw a backpack at resident hittimg him in the face.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver complaint findings for the above allegations. LPA was greeted by administrator and explained the reason for the visit.

Based on interviews with staff and residents the alleagation is Substantiated. S1 and S2 confirm that R1 had their backpak thrown at them, and as a result R1 was hit in the face. The department has investagaged this complaint and the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 6, deficiencies are being cited on the attached 9099D during this visit.

If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was given.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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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Control Number 27-AS-20240515152858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CABRERA'S GUEST HOME
FACILITY NUMBER: 342700266
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
82072(a)(1)
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 (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee shall provide proof of staff training, for the cited (personal rights) section this will be completed and submitted to the LPA's email at Kesha.lewis@dss.ca.gov by COB 7/29/2024.
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Based on interviews conducted, it was learned that S1 thew R1'S backpack at them and it hit R1 in the face. This poses an potential health, safety, and personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
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