390313873-3-3-2023-27-AS-LKIG-CQ6UNJ-20230322154402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 390313873
Report Date: 03/03/2023
Date Signed: 03/03/2023 10:35:08 AM

Unsubstantiated

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
02/06/2023 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230206135639

FACILITY NAME:	SHIRLEY'S CARE HOME #2, INC.		FACILITY NUMBER:	390313873
ADMINISTRATOR:	GAPASIN, ELPIDIO & SHIRLEY		FACILITY TYPE:	735
ADDRESS:	3123 DARTMOUTH COURT		TELEPHONE:	(209) 474-9302
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	6	CENSUS: 5	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Mary Bailey		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal rights Vilation

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPA) Kesha Lewis conducted an unannounced complaint visit on 03-03-23 and was met by staff to discuss the findings of the complaint. Current census of the facility was 5

The purpose of this visit was to complete this complaint investigation and deliver the findings to this facility.

The complaint allegations listed above were investigated. Based on interviews and information gathered during the course of this investigation, it was determinded that the allagation is unsubstaantiated. The residents, facility staff and management and other witnesses were interviewed by LPA Lewis. The residents and all other individuals interviewed and didn't beliveve that the allegations occurred. Futher documutation in R1's file supported the finding.

An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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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