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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700410
Report Date: 11/09/2021
Date Signed: 11/10/2021 08:41:51 AM

Substantiated


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
10/01/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211001095900
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: 3DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Soares C.TIME COMPLETED:
02:54 PM
ALLEGATION(S):
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Clients are assisting other clients with bathing.
INVESTIGATION FINDINGS:
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LPA Johnson arrived at the care facility and met with Administrator to deliver findings for the above allegation.

Allegation: Clients are assisting other clients with bathing. Based on interviews conducted with the residents and Administrator it was confirmed that R1 assist R2 with bathing. R1 and R2 have a sister like relationship and R1 will ask R2 if she can assist R1 with washing her back and picking out clothing for R2.

The Administrator has counseled with R1 and informed her that this practice is not acceptable. R1 has a history of wanting to complete chores around the house etc... R1 moved into the facility in 2014 and was the only resident until 2018 when R2 moved into the facility.
Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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 4
Control Number 27-AS-20211001095900
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
VISIT DATE: 11/09/2021
NARRATIVE
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Based on LPA’s observations, interviews conducted and records reviewed, 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20211001095900
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: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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The planning team will address this issue at R1's next IPP or quarterly meeting. The IPP will be updated to assist R1 with replacement behaviors. Although this is a level two home R1 and R2 have
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This requirement was not met based on interviews conducted. R1 is assisting R2 with hygiene. This poses a potential risk to residents in care
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behavior challenges that need planning team assistance. Please forward any addendums or updates to CCL
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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: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
10/01/2021 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20211001095900

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: 3DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Soares C.TIME COMPLETED:
02:54 PM
ALLEGATION(S):
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Administrator is not keeping information regarding clients confidential.
INVESTIGATION FINDINGS:
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Based on interviews conducted the facility has shared information as it is related to questions asked regarding concerns of R3 and his ability to feel safe in the facility.

The facility has shared general information with the family of R3 as a result of R3's questions. The information shared was not confidential and was given to help R3's family understand that placement at the homes is supervised by the Service Coordinator from Valley Mountain Regional Center and that the residents compatability is considered when the residents are placed. The facility did not violate HIPPA regualtions, however the facility did share information with the family to address questions they had about R3 concerns.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation of personal rights is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
10/01/2021 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20211001095900

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: 3DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Soares C.TIME COMPLETED:
02:09 PM
ALLEGATION(S):
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Administrator is not keeping information regarding clients confidential.
INVESTIGATION FINDINGS:
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Based on interviews conducted, it was confirmed that the facility shared information based on questions that were asked about other residents in the facility.

R3 expressed concerns about other residents in the facility and these concerns were brought to the attention of the facility. The facility addressed the concerns of the family by providing information that was related to the questions asked, but not confidential information related to diagnosises, medical history or any other potential HIPPA violations.

The facility take the residents to appointments and all residents go. The conversations that happen after the appointments made be overheard by other residents. The information is general and not confidential.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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