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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700410
Report Date: 07/27/2022
Date Signed: 09/14/2022 10:21:31 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
06/13/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220613172138
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:
07/27/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:C. SoaresTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility not following Covid-19 mask mandate.
Facility side gates are locked.
Facility's emergency plan is inaccurate.
INVESTIGATION FINDINGS:
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LPA Johnson arrived at the care facility and met with Administrator to deliver findings for the above allegation.

Based on interviews conducted with the Administrator the facility had a unannouced visit and the alleged items were confirmed. The facility locks the gates to secure the facility. The Administrator stated that the facility has had several break-ins and property has been taken from the backyard as well as the front yard.

LPA reviewed the emegency plan and confirmed that one side of the gate is not identified as an emergency exit in her CCL emergency plan.

Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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
Control Number 27-AS-20220613172138
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: 07/27/2022
NARRATIVE
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The Administrator also confirmed that she did not have a mask on because the whole facility is vaccinated and they did not have any visitors at the time. She stated she was eating when the call for the virtual visit was answered.

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: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220613172138
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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
87203(a)
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Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by: The facility
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Plan of correction: the facility will update the plan and have the locks removed immediately. send proof POC due to CCL by due date
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Facility side gates are locked.
Facility's emergency plan is inaccurate the exit was not identifed on the facility sketch.
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Type B
09/30/2022
Section Cited
HSC
1569.58(a)(2)
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HSC 1569.58(a)(2)Employee Actions: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.
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Licensee agrees to submit plan to be in compliance with this regulation to LPA by POC due date of 9/30/2022
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This requirement is not met as evidence by: The Administrator also confirmed that she did not have a mask on because the whole facility is vaccinated and they did not have any visitors at the time. She stated she was eating when the call for the virtual visit was answered.
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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: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3