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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397002232
Report Date: 01/17/2024
Date Signed: 01/17/2024 02:16:06 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
01/08/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240108092143
FACILITY NAME:DE ORO GUEST HOME #2FACILITY NUMBER:
397002232
ADMINISTRATOR:DORIS B MADRIDFACILITY TYPE:
735
ADDRESS:1648 KNICKERBOCKER COURTTELEPHONE:
(209) 670-4458
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 6DATE:
01/17/2024
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Nellen Van De PolTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not maintain a comfortable temperature for residents at all times
INVESTIGATION FINDINGS:
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On 1-17-24 at 10:22am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Licensee Nellen Van De Pol and explained the purpose of the visit. During this investigation, LPA conducted a facility observation. LPA also interviewed Licensee and three residents in care. During investigation, LPA observed thermostat displaying temperature at 66*F with set temperature at 75*F. Interviews conducted also revealed that facility temperature is not maintained between 68*F and 85*F per regulatory requirements during various times of the day and night.

As a result of this investigation, there is a preponderance of evidence to concluded that facility did not maintain the regulatory temperature of 68*F and 85*F, therefore this allegation is SUBSTANTIATED. CItation is issued under Title 22, division 6. An exit interview was conducted with Staff2 (S2) and a copy of this report was provided to S2. Licensee Nellen Van De Pol departed facility prior to completion of investigation and gave permission for S2 to sign in her absence. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
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-20240108092143
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: DE ORO GUEST HOME #2
FACILITY NUMBER: 397002232
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
80088(a)(1)
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Furniture, Fixtures, Equipment, and Supplies. (a) A comfortable temperature for clients shall be maintained at all areas. (1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). This requirement was not met as evidenced by:
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Licensee will read regulation 80088(a)(1) and submit a signed declaration of understanding to LPA by POC due date.

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Based on observation and interview, Licensee did not maintain a temperature between 68*F and 85*F. This posed a potential health and safety risk to residents in care.
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Licensee contacted repair company during LPAs visit to inspect unit and ensure proper functionality. Licensee to send results of inspection to LPA by POC due date.
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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: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2