392790073-9-8-2021-27-AS-KHOS-C6VKQ4-20210915080545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392790073
Report Date: 09/08/2021
Date Signed: 09/08/2021 04:10:44 PM

Unsubstantiated

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
08/19/2021 and conducted by Evaluator Bruce Jacobs

COMPLAINT CONTROL NUMBER: 27-AS-20210819092412

FACILITY NAME:	MARTIN'S CIRCLE		FACILITY NUMBER:	392790073
ADMINISTRATOR:	MARTIN, KENNETH		FACILITY TYPE:	735
ADDRESS:	1735 LARAMIE WAY		TELEPHONE:	(209) 482-7409
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	4	CENSUS: 3	DATE:	09/08/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Aryanna Rhodd		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident's car insurance was cancelled without resident's (C-1) consent.

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs conducted an unannounced complaint visit at the facility and met with Aryana Rhood and spoke to Administrator Kenneth Martin by phone to discuss and complete this complaint investigation. LPA provided findings regarding the allegations listed above. The investigation was conducted by LPA Jacobs and consisted of reviews of the facility records and interviews with facility management and staff. The residents and other witnesses were contacted and interviewed.

The complaint allegation listed above was investigated. The resident, facility staff and management and other witnesses were interviewed by LPA Jacobs on 08/20/21. The resident and Facility Administrator stated that the insurance was cancelled by mutual agreement. Other witnesses interviewed provided conflicting information on the allegation. Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegation is determined to be UNSUBSTANTIATED.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred

Exit interview conducted, report provided to the Aryanna Rhodd.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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