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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397000250
Report Date: 11/21/2023
Date Signed: 11/21/2023 03:37:39 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
10/19/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20231019135947
FACILITY NAME:MELMAR'S GUEST HOME #2FACILITY NUMBER:
397000250
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:6801 MONTAUBAN AVENUETELEPHONE:
(209) 683-6876
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 4DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Sherrymel CameroTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff inappropriately transported the clients while in care
Staff mishandled a client's medication while in care
INVESTIGATION FINDINGS:
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On 11-21-23 at 2:02pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Assistant Administrator Sherrymel Camero and explained the purpose of the visit. Administrator Maricor Junson was made aware of LPAs visit and purpose via telephone. During this investigation, LPA conducted interviews with 4 residents in care and Administrator. LPA also reviewed facility file documentation including medication log sheets and incident reports.
Allegation: Staff inappropriately transported the clients while in care. LPA conducted interviews as stated above and reviewed incident reports dated 10-17-23. Based on interviews and record reviews, it was revealed that on 10-1-23, a staff member on duty transported four residents in care to a nearby shopping destination using the facility’s vehicle. It was further revealed that staff member who transported residents did not possess a valid driver’s license at the time of the incident. Additionally, it was revealed that clients were unharmed physically, but frightened as a result of the experience, due to staff member unfamiliar with the operation of the vehicle. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
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 6
Control Number 27-AS-20231019135947
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: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250
VISIT DATE: 11/21/2023
NARRATIVE
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Allegation: Staff mishandled a client’s medication while in care. LPA conducted interviews as stated above and reviewed client medication log sheets from September 2023 and October 2023. Based on interviews and record reviews, it was revealed that resident1 (R1) did not receive multiple medications as prescribed and as indicated on medication log sheets during the dates of 9-29-23 and 9-30-23. It was determined that a total of 5 medications were not given through various dosage times between 7am and 8pm. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citations are issued under Title 22, Division 6 and noted on LIC 9099D. Civil penalties in the amount of $250 each are issued in addition to citations due to repeat violations of Section 80075(a) and Section 80072(a)(2) within a 12-month period. An exit interview was conducted with Sherrymel Camero, and a copy of this report was provided to Sherrymel. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20231019135947
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: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2023
Section Cited
CCR
80075(b)
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80075(b) Health Related Services. (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee to submit a plan describing how staff will ensure residents receive medications as prescribed. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure R1 receive medications as prescribed as indicated on the medication log sheets. This posed an immediate health and safety risk to residents in care.
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Licensee to ensure completed staff training on medication record keeping and following physician’s orders. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks from the date of citation issuance.
Type B
11/30/2023
Section Cited
CCR
80072(a)(2)
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80072(a)(2) Personal Rights (a) …each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Licensee will read regulation 80072(a)(2) and submit a signed declaration of understanding to LPA by POC due date. Licensee to submit a plan on how to ensure only properly licensed staff are safely transporting clients in vehicles.
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 Based on interview and record review, facility staff drove four residents in facility’s vehicle while not possessing a valid driver’s license. This posed a potential 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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/19/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20231019135947

FACILITY NAME:MELMAR'S GUEST HOME #2FACILITY NUMBER:
397000250
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:6801 MONTAUBAN AVENUETELEPHONE:
(209) 683-6876
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 4DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Sherrymel CameroTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff made moldy food for the clients while in care
Staff are not following the noted food menu
Staff are not changing the clients linens while in care
Staff do not keep the facility free from bugs
Staff yells at the clients while in care
Staff threatens the clients while in care
INVESTIGATION FINDINGS:
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On 11-21-23 at 2:02pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Assistant Administrator Sherrymel Camero and explained the purpose of the visit.Administrator Maricor Junson was made aware of LPA's visit and purpose via telephone. During this investigation, LPA conducted interviews with 4 residents in care and Administrator. LPA also reviewed facility file documentation including facility menu, pest control agreement, and photographs submitted by outside party. Additionally, LPA conducted facility observation on 10-20-23.

Allegation: Staff made moldy food for the clients while in care. LPA conducted facility observation and reviewed photographs as stated above. LPA also conducted interviews as stated above. LPA observed food on hand at facility which did not contain moldy type images. Additionally, LPA observed food on hand and available to residents to be adequate and not expired. Based on photographs reviewed and interviews conducted, it was undetermined if food in the photographs was that of facility’s. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20231019135947
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: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250
VISIT DATE: 11/21/2023
NARRATIVE
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Allegation: Staff are not following the noted food menu. LPA reviewed facility menu for October of 2023 and observed food on hand at facility. Based on record review and observation, it was determined that food available to residents does match the menu food items listed. Interviews conducted with residents and Administrator revealed changes in the menu occur at resident’s requests only. Furthermore, there were no corroborated statements from facility staff and residents not following the established menu. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff are not changing the clients’ linens while in care. LPA conducted facility observation and interviews as noted above. Based on interviews conducted, it was revealed that linens are changed once per week or more often as necessary. LPA further observed an adequate amount of linen available to residents in care. Linen observed by LPA including linen in current use and extra stored linen did not reveal stains or foul odors. As a result, there is not a preponderance of evidence to conclude that bed linens are not changed, and this allegation is UNSUBSTANTIATED.

Allegation: Staff do not keep the facility free from bugs. LPA conducted facility observation and conducted interviews as noted above. LPA also reviewed the facility’s pest control agreement. During observation and based on interviews conducted, the facility did not contain any uncontrolled bug presence. Additionally, the facility has a current pest control agreement in place to treat insects. Furthermore, the facility was observed to possess a machine specifically in use to control bug presence in resident rooms and common areas. As a result, there is not a preponderance of evidence to conclude that staff do not keep the facility free from bugs, therefore, this allegation is UNSUBSTANTIATED.

Allegation: Staff yells at the clients while in care. LPA conducted interviews and facility observation as noted above. Based on interviews, it was revealed that although various staff members contain a loud tone of voice, it was not interpreted as staff members yelling directly at residents with intention to cause harm. Additionally, LPA did not observe staff members yelling at residents in care. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff threatens the clients while in care. LPA conducted interviews and facility observation as noted above. Based on interviews, it was revealed that staff members have not made verbal or physical type threats towards residents in care. {Cont. on 9099C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20231019135947
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: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250
VISIT DATE: 11/21/2023
NARRATIVE
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Additionally, based on facility observation, LPA did not observe staff making verbal or physical threats towards residents. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Sherrymel Camero, and a copy of this report was provided to Sherrymel. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6