<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 390317879
Report Date: 10/10/2023
Date Signed: 10/10/2023 06:37:31 PM

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
08/01/2023 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20230801155030
FACILITY NAME:TACSION'S GUEST HOMEFACILITY NUMBER:
390317879
ADMINISTRATOR:TACSION, MYRNA L.FACILITY TYPE:
735
ADDRESS:4314 ESTATE DRIVETELEPHONE:
(209) 957-0185
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:6CENSUS: 5DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marife De LeonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client sustained unexplained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to interview R1 and deliver findings for the above allegations. LPA was greeted by staff and explained the reason for the visit.

Allegation 1 Client sustained unexplained injury while in care is Unsubstantiated. Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.

The resident and all other individuals interviewed denied that R1 was injured.

During LPA's inspection there was a small red mark visible observed on R1.

Exit interview conducted, report given.

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

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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 1