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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004502
Report Date: 08/03/2021
Date Signed: 08/03/2021 10:56:35 AM



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
06/03/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210603144940
FACILITY NAME:GOLDEN PINE GUEST HOMEFACILITY NUMBER:
397004502
ADMINISTRATOR:MARIVIC TEANO-CHUAFACILITY TYPE:
740
ADDRESS:314 WEST PINE STREETTELEPHONE:
(209) 334-6441
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:15CENSUS: 15DATE:
08/03/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Angelita Yapo, CaregiverTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Resident was abused by another resident while in care.
INVESTIGATION FINDINGS:
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On 08/03/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA White discussed the purpose of the visit and the elements of the allegation with Caregiver, Angelita Yapo and over the phone with Administrator, Marivic Teano.

During the course of investigation, LPA collected documents and conducted interviews. Based on interview, Resident #1 (R1) was physically abused by one male who shook his jaw and one female who slammed the door on his finger. Based on interview on 06/10/2021, Staff #1 (S1) stated she does not remember any physical contact between residents. Based on interview on 06/17/2021, Staff #2 (S2) stated there was no physical abuse between R1 and R2. S2 stated there was only verbal abuse between R1 and R2. Based on R1’s interview, R1 was unable to provide names or any additional information.

Report continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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-20210603144940
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: GOLDEN PINE GUEST HOME
FACILITY NUMBER: 397004502
VISIT DATE: 08/03/2021
NARRATIVE
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On 08/03/2021, LPA interviewed 7 residents and 2 staff members. Based on interview with 7 residents, 7 of 7 residents stated there is no resident on resident abuse or physical altercations. 7 of 7 residents stated there has only been resident on resident arguments. Based on staff interviews, 2 of 2 staff stated there has been no resident on resident abuse or physical altercations. However, the residents that were interviewed have mental health conditions and there is no additional information regarding R1 being abused by another resident while in care.

Based on information obtained, LPA determined this allegation to be UNSUBSTANTIATED- means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. There are no citations being issued today.

Exit interview conducted with Caregiver and copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2