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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 390304570
Report Date: 01/26/2023
Date Signed: 02/02/2023 03:13:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
12/22/2022 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221222164154
FACILITY NAME:SOLIDUM GUEST HOMEFACILITY NUMBER:
390304570
ADMINISTRATOR:SOLIDUM, NORMAFACILITY TYPE:
740
ADDRESS:3127 APPLING CIRCLETELEPHONE:
(209) 474-6182
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:6CENSUS: 6DATE:
01/26/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Celia BasilioTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not properly store food at facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced complaint visit to inform the licensee of complaint findings mentioned above. LPA met with Staff and explained the purpose of the visit.

Based on LPA'S interview of Staff 1 (S1) the above allegation of -Staff do not properly store food at facility is SUBSTANTIATED.

CCLD finds the allegation of Staff do not properly store food at facility to be SUBSTANTIATED. A finding that the complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on the attached 9099D

Exit interview conducted and a copy of the report and appeal right given via email as LPA'S printer in not working at this time.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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 2
Control Number 27-AS-20221222164154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SOLIDUM GUEST HOME
FACILITY NUMBER: 390304570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2023
Section Cited
CCR
87555(b)(8)
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General Food Service Requirements
(b) The following food service requirements shall apply:...
(8) All food shall be of good quality. ...
This requirement was not met as evidenced by:
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The Licensee threw away the yogurt, juice, and cottage cheese in addition, an in service training will conducted and proof of training will be sent to LPA Lewis by POC due Date.
Kesha.Lewis@dss.ca.gov
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Based on LPA'S interview with S. S1 stated the food order was delivered the day before the VMRC visit and it was by accident that the food was left out. This poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
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