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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800830
Report Date: 01/22/2025
Date Signed: 01/22/2025 11:35:57 AM

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
01/16/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250116123617
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: 33DATE:
01/22/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Lopez, Back up AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are abusing resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Back up Administrator Maria Lopez and explained the purpose of the visit.

LPA requested the following records: Resident 1's (R1) Admission Agreement, Appraisal Needs and Service Plan, Resident Roster, Staff Roster with telephone numbers, staff schedule for January 2025, and discharge paperwork from Hospital.

LPA conducted interviews with Staff, Witness and Resident on 01/22/2025 around 10:15-10:45 am.

On the allegation: Staff are abusing resident. LPA Interviews revealed R1 had a unwitnessed fall and was transported to the hospital this month, roommate found R1 on floor and called for staff, which then called 911. R1 is very hard of hearing and Witness 1 (W1) was at the hospital with R1 and told hospital staff that you have to write down questions and let him write down the answers but if verbally asked he will not understand or answer correctly due to hearing difficulties. Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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-20250116123617
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: 01/22/2025
NARRATIVE
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R1 is an independent resident that takes care of most of R1's own needs, lives in assisted living with a roommate that R1 has had for several years, and does medication management through San Luis County Mental Health. R1 is a very nice person, able to communicate in writing easier than verbally as he does not hear things correctly to understand oral questions, and R1 goes out into the community daily. R1 has never reported any abuse to the facility, to R1's roommate, to County Mental Health Services or to R1's friend. R1 was discharged by the hospital back to the facility and the facility staff set up all follow up appointments R1 needed. W1 takes R1 to all appointments. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report printed for back up Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2