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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700410
Report Date: 07/26/2023
Date Signed: 07/26/2023 12:12:58 PM

Unsubstantiated


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
12/01/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221201082846
FACILITY NAME:A.J GUEST HOMEFACILITY NUMBER:
392700410
ADMINISTRATOR:SOARES, CONCEPCION BFACILITY TYPE:
735
ADDRESS:1854 ERICKSON CIRTELEPHONE:
(209) 943-1381
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: 4DATE:
07/26/2023
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:C. SoaresTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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The licensee is not financially solvent
INVESTIGATION FINDINGS:
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Based on the information received from the licensee and reviewed, it appears that the facilities are generating enough income from operations to cover expenses. The review of the operational records did not indicate any default or late payments. Additionally, the review of the facilities bank statements and assets indicate that the adequate financial resources were maintained to meet operational costs.

Moreover, the provided records showed that the licensee has complied and applicable laws and regulations. Therefore, it appears that the licensee has a financial plan that complies with financial requirements as contained in Section 87213 Finances. It should also be noted that the cooperative nature of the licensee when conducting the audit demonstrates an accountability for the corporation, and a willingness to furnish information regarding the finances of the facility during the audit.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
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 3
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
12/01/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221201082846

FACILITY NAME:A.J GUEST HOMEFACILITY NUMBER:
392700410
ADMINISTRATOR:SOARES, CONCEPCION BFACILITY TYPE:
735
ADDRESS:1854 ERICKSON CIRTELEPHONE:
(209) 943-1381
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: 4DATE:
07/26/2023
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:C. SoaresTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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The licensee did not comply with the terms and agreement on the admissions agreement
INVESTIGATION FINDINGS:
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Based on records reviewed the facility was billing R1's family for damage to the facility as a result of behaviors identified in the IPP for R1. The facility had an agreement with the family to have R1 stay at this facility which is a level 3 care home.

R1 had a history of aggressive behaviors and property destruction, based on the review of correspondence with the family and the facility, the facility was informing the family of incidents related to property destruction and provided invoices for the repairs. This was not part of the admissions agreement nor was it part of the IPP developed to assist R1 in maintaining placement.

The licensee confirmed that the family wanted to assist with repairs and even with assistances with those repairs the facility still paid additional money to have the damages fixed. Nevertheless the facility did not comply with the terms of the admissions agreement.

The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of regulations, Title 22 are being cited on the attached LIC9099D.

Exit Interview and copy of appeal rights and report provided.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20221201082846
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: A.J GUEST HOME
FACILITY NUMBER: 392700410
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
80068(h)
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(h) The licensee shall comply with all terms and conditions set forth in the admission agreement. This requirement is not met as evidenced by
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The facility will provide the residents with an updated admissions agreement when additional services are required.
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the lack of Costs for optional services identified in the admissions agreement and the lack of terms for the addition identified in the IPP for R1.
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3