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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397000250
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:03:51 PM

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
08/24/2021 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210824095221
FACILITY NAME:MELMAR'S GUEST HOME #2FACILITY NUMBER:
397000250
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:6801 MONTAUBAN AVENUETELEPHONE:
(209) 478-4811
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 6DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maricor CameroTIME COMPLETED:
03:16 PM
ALLEGATION(S):
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Facility staff are not present at the facility
INVESTIGATION FINDINGS:
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On 8/24/21 at 1:53pm Licensing Program Analyst (LPA) arrived unannounced to open and investigate the complaint allegation listed above. LPA met with Administrator Maricor Camero and explained the purpose of the visit. During the course of this investigation LPA reviewed resident1 (R1)'s Individualzed Program Plan (IPP) as well as staffing roster and resident roster. LPA also conducted interviews with Administrator, Staff1 (S1) and R1. Based on interviews it was determined that on 8/20/21, R1 was left in the facility alone with no supervision for approximately 1 hour while Administrator and S1 were out of the facility with other residents. Based on interviews it was determined that there was no additional staff available for supervision of R1 during this time.

Based on interviews and record reviews it is determined that this allegation meets the preponderance of evidence standard and is therefore SUBSTANTIATED. Defeciencies were cited under TItle 22, Divsion 6 on form 9099D. A copy of this report and appeal rights were left with Administrator Maricor Camero.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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-20210824095221
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: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
08/25/2021
Section Cited
CCR
80078(a)
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80078 Responsiblity of provding care and supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee will submit a plan ensuring 24/7 available staff for residents in care and avoiding staff left alone. Plan to be submitted by POC due date.

Licensee will read regulation 80078(a) and submit a signed statement of understanding to LPA by POC due date.
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Based on interviews and record reviews it was determined that Licensee did not ensure proper care and supervision for R1 as R1 was left in facility for approximately 1 hour without staff coverage on 8/20/21. This poses and immediate health, safety and resident rights risk to residents in care.
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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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2