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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701183
Report Date: 02/21/2024
Date Signed: 03/04/2024 12:39:42 PM

Unsubstantiated


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
11/22/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231122105402
FACILITY NAME:STAR BLOOM CAREHOMEFACILITY NUMBER:
392701183
ADMINISTRATOR:ACUAVERA, ARLENEFACILITY TYPE:
735
ADDRESS:2410 LAGUNA CTTELEPHONE:
(209) 641-9320
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Arlene AcuaveraTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are physically abusing resident
Staff are withholding residents personal belongings
INVESTIGATION FINDINGS:
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On 02/21/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA) Arlene Acuavera and explained the purpose of the visit.
The purpose of the visit was to deliver complaint findings for the allegations above.
Current census was 6. 5 out of 6 residents were out at their respective day program at this time.
A brief interview with FDA Acuavera was conducted.
Allegation: Staff are physically abusing resident
It was alleged that staff have been physically abusing a resident. Based on interviews conducted it was denied by any staff members that they grabbed the resident and caused any harm. An additional interview with the resident was conducted where it was confirmed that the staff did not grab the resident by their body or by their wheelchair. It was stated that there was bruise on the residents arm, however, it was believed by the resident that they hit a corner of a wall but do not recall when it happened. Based on the information gathered, it is unclear if the staff are physically abusing the resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
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 2
Control Number 27-AS-20231122105402
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: STAR BLOOM CAREHOME
FACILITY NUMBER: 392701183
VISIT DATE: 02/21/2024
NARRATIVE
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Allegation: Staff are withholding residents personal belongings
It was alleged that staff are withholding residents personal belongings. Based on interviews conducted it was denied by staff that they withhold any residents belongings. It was stated that all residents are able to keep their belongings at all times. It was denied by residents that they are not able to keep their belongings and deny that staff take their belongings at any time. It is unclear at this time that staff are withholding residents personal belongings.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2