392700049-8-27-2021-27-AS-KHOS-C6NLQQ-20210908085751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700049
Report Date: 08/27/2021
Date Signed: 08/27/2021 04:46:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/21/2021 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210721084730

FACILITY NAME:	ARLYN'S GUEST HOME		FACILITY NUMBER:	392700049
ADMINISTRATOR:	DE LA CRUZ, ARLYN M		FACILITY TYPE:	740
ADDRESS:	1633 S STOCKTON STREET		TELEPHONE:	(209) 915-3962
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY:	6	CENSUS: 5	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	Arlyn		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff refused to issue a refund.

INVESTIGATION FINDINGS:

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LPA Albert Johnson made an unannounced visit to this facility today to deliver findings for the allegation listed above.

Based on interviews conducted with placement agency and the facility. The department finds that the allegation to be unfounded. It was reported that R1 was sent to Arlyns Guest Home on and didn't like it. They (the family) took her out of the home immediately. They paid the placement agency $5193.54. This includes $2000.00 entrance fee and rent for the rest of May and June. However, the facility never recieved money for R1. As a result, the contract between R1's family and the placement agency will need to be addressed as a civil matter to recoup the funds paided.

Continued

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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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Control Number 27-AS-20210721084730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARLYN'S GUEST HOME	FACILITY NUMBER: 392700049
	VISIT DATE: 08/27/2021

NARRATIVE

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The facility did not start documentation for residency, R1 was out of the county and the Licensee was unable to do a pre-assessment, but was able to review the Physician's report and intended on completing the paper work when R1 arrived with family.

The facility did they receive any of the monies paid to the placement agency and therefore is not responsible for repaying or refunding any fees paid to the placement agency.

"This agency has investigated the complaint alleging the "Staff refused to issue a refund."

The complaint is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."

An exit interview was conducted a copy of this report was provided

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

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