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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370804165
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:51:06 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Lizzette Tellez
COMPLAINT CONTROL NUMBER: 08-AS-20210819144211
FACILITY NAME:GOOD SAMARITAN BOARD AND CARE FACILITYFACILITY NUMBER:
370804165
ADMINISTRATOR:FAYE MAYOFACILITY TYPE:
740
ADDRESS:6255 MCHANEY COURTTELEPHONE:
(619) 267-2445
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 6DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator, Faye MayoTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Facility did not have a working shower
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced complaint visit to investigate the above-mentioned allegation. LPA was met by Caregiver, Gloria Ganduela, and was granted entry into the facility. LPA met with Administrator, Faye Mayo, and discussed the purpose of the visit.

Investigation consisted of interviews with staff, residents, outside sources, and a tour of the facility. It was alleged that the facility does not have a working shower, specifically, that there was not a working shower in the facility in 2015. During a tour of the facility, LPA observed two full bathrooms with two working showers in good repair. Interviews with staff, residents, and outside sources, did not support the allegation. Individuals interviewed did not report concerns regarding the facility showers. The Department has investigated the above-mentioned allegation and based upon interviews and LPA observations, has found that there is insufficient evidence to support or corroborate the alleagtion. Therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Ms. Mayo and a copy of this report, along with
Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic
receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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