392700661-1-8-2025-27-AS-KHOS-DD5R85-20250121114721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700661
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:16:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20241211084125

FACILITY NAME:	CASA DE ESPERANZA		FACILITY NUMBER:	392700661
ADMINISTRATOR:	BROWN, PAMELA & MAGANA, LU		FACILITY TYPE:	735
ADDRESS:	400 OLIVINE AVENUE		TELEPHONE:	(510) 385-8463
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY:	4	CENSUS: 2	DATE:	01/08/2025
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Caselita Jones		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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8
9

Absense of staff when resdients are present

INVESTIGATION FINDINGS:

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5
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On 01/08/25, Licensing Program Analyst (LPA) Kesha Lewis and Licensing program manager (LPM) Liza King arrived unannounced to continue the complaint investagation for the allegations noted above. LPA met with staff explained the purpose of the visit.

LPA interviewed R1-R2 and S1. LPA Lewis toured facility to ensue complince with title 22 regulations.

Based on observations and interviews with residents and the a visit from valley mountian reginal (VMRC) on 12/06/2024 During the visit from VMRC residents were found to be in the facility with no staff by VMRC legasion Isebella Dalman.

the complaint is determined to be SUBSTANTIATED. As a result, the preponderance of evidence standard for this allegation is met, therefore, this allegation is SUBSTANTIATED.

Deficiencies cited see 9099D page per California Code Regulation, TITLE 22.

Exit interview was conducted and a copy of the report and appeal rights given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20241211084125

FACILITY NAME:	CASA DE ESPERANZA		FACILITY NUMBER:	392700661
ADMINISTRATOR:	BROWN, PAMELA & MAGANA, LU		FACILITY TYPE:	735
ADDRESS:	400 OLIVINE AVENUE		TELEPHONE:	(510) 385-8463
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY:	4	CENSUS: 2	DATE:	01/08/2025
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Caselita Jones		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff sleeping in living room during night hours

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
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11
12
13

Based on interviews with staff and resident the above allagation is UNSUBSTANTIATED. Due to conflicting interviews between residents and staff.

Note that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was held and a copy of this report was given.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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-20241211084125

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DE ESPERANZA	FACILITY NUMBER: 392700661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/08/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/09/2025 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	1569.2 Definitions - (c) “Care and supervision” means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.	1 2 3 4 5 6 7	An attestation will be signed by all staff stating that all staff understand that residents must be monitored at all times. This document will be submitted to CCL at kesha.Lewis@dss.ca.gov by 01/09/25.
	8 9 10 11 12 13 14	The above requirement was not met as evidenced by: Based on interviews and observations during a VMRC visit on 12/06/2024 residents were left unsupervised. This posed an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3