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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800830
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:38:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/16/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230516133425
FACILITY NAME:AMERICAN CARE HOMEFACILITY NUMBER:
405800830
ADMINISTRATOR:LIXIA ZHANGFACILITY TYPE:
735
ADDRESS:1240 EL CAMINO REALTELEPHONE:
(805) 466-9029
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:38CENSUS: 38DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Maria Lopez, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff discharged a firearm on facility grounds
Staff did not ensure firearms were properly stored and inaccessible to clients in care
INVESTIGATION FINDINGS:
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On 5/19/23 at 11:20 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint investigation to the facility above. LPA met with Maria Lopez, Administrator, and explained the reason for the visit.

On the allegations, “Staff discharged a firearm on facility grounds,” and “Staff did not ensure firearms were properly stored and inaccessible to clients in care,” the complainant was concerned that they had witnessed staff shooting guns near the chicken pen and air condition cooler. Complainant was uncertain if staff were shooting at the ground or in the air and was concerned that it may psychologically affect clients in care. To investigate, LPA interviewed the administrator, staff, and clients, and made observations.

Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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 2
Control Number 29-AS-20230516133425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMERICAN CARE HOME
FACILITY NUMBER: 405800830
VISIT DATE: 05/19/2023
NARRATIVE
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On 5/19/23 at 11:25 am, LPA interviewed the administrator. Administrator explains that some staff live in the cottages south of the property and that she has never seen staff or anyone else use a gun on facility property nor near the facility. She confirms firearms are not stored on the property and clients are not allowed to store firearms.

On 5/19/23 between 11:35 am and 12:20 pm, LPA interviewed staff. Staff say they have never witnessed anyone using guns or firearms on the property or near the property. They say they have not heard fireworks that may have sounded like gunshots. Staff who live on the adjacent property say they do not own a gun and have never used a gun on the facility property nor on their property.

On 5/19/23 between 11:45 am and 12:52 pm, LPA interviewed clients. Clients say they have not witnessed anyone using a gun on the property. Two clients say they have heard gun shots in the distance and were not concerned for their safety.

On 5/19/23, LPA toured the facility. LPA did not witness any firearms being stored, no gun shells, and no evidence that guns had been used nor stored on the property.

Based on the evidence obtained, the allegations, “Staff discharged a firearm on facility grounds,” and “Staff did not ensure firearms were properly stored and inaccessible to clients in care,” are deemed Unsubstantiated at this time.

Exit interview conducted and report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2