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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700787
Report Date: 02/11/2025
Date Signed: 02/11/2025 10:41:45 AM

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
01/07/2025 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250107084327
FACILITY NAME:LIBBIE CARE HOMEFACILITY NUMBER:
392700787
ADMINISTRATOR:RAM, AVINESHFACILITY TYPE:
735
ADDRESS:558 E EDISON STTELEPHONE:
(209) 824-5993
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:5CENSUS: 3DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jet Tang TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff leaves clients in the home without care and supervision
Licensee allows uncleared staff in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to deliver complaint findings.LPA wass met by staff. LPA explained the purpose of the visit to staff.

Based on the information gathered, through interviews with Staff and residents, the allegations Staff leaves clients in the home without care and supervision and Licensee allows uncleared staff in the facility are SUBSTANTIATED.

see 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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
Control Number 27-AS-20250107084327
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: LIBBIE CARE HOME
FACILITY NUMBER: 392700787
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
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. This requirement was not met as evidenced by:
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Licensee will submit a detailed plan of how they will ensure staff schedules meet each resident's staffing ratio need by POC due date.

Kesha.Lewis@dss.ca.gov
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The licensee did not ensure staff were present in the facility to meet facility staffing requirements, which is a potential health, saftey, and personal rights risk to residents in care.
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Type A
02/12/2025
Section Cited
CCR
80019
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80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f)

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Administrator shall formulate a plan to ensure that staff that is excluded are not allowed in the facility. Proof of plan to be sent to Kesha.Lewis@dss.ca.gov
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-This requirement has not been met as evidenced by:based on interviews excluded property owner has been see in the facility.
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Civil penalty is being assessed today for facility allowing an excluded person to work in facility.
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: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250107084327
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: LIBBIE CARE HOME
FACILITY NUMBER: 392700787
VISIT DATE: 02/11/2025
NARRATIVE
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Based on interviews with staff and residents is was learned that residents are being left at the facility by themselves and that a person that was excluded from being present in the facility has been present and representing themvself as a sraff member of the facility. Based on interviews, the preponderance of evidence standard is met, and these allegations are SUBSTANTIATED.

Citations are issued as indicated on LIC 9099D. An exit interview was conducted Appeal rights provided.

LPA Lewis spoke with Renne Tang on the phone and explained the purpose for the visit and the findings for the investigation.

Ncc notice was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3