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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800830
Report Date: 02/11/2025
Date Signed: 02/11/2025 03:07:35 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
02/05/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250205160849
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: 34DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maria LopezTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff do not ensure water is safe for human consumption
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) De Leon and Haner-Tomasko and conducted a 10-day Complaint visit to the facility above. LPA met with Maria Lopez Back up Administrator and explained the purpose of the visit.

LPA's toured the full facility inside and outside, conducted interviews and requested records from 9:15am-1:50pm.

On the allegation: Staff do not ensure water is safe for human consumption. LPA's toured 10 rooms, Bedrooms 1, 3, 5, 8, 10, 12, 14, 16, 18 and 20 and 4 restrooms with showers. LPA's checked 6 sink faucets in the rooms with bathrooms and the common area restrooms. The faucet water temperatures were tested and measured at 114.3, 120.0, 108.9 and 114.2 degrees. The sinks did not have any foul odors.
Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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-20250205160849
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: 02/11/2025
NARRATIVE
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The facility has a large filter drinking water dispenser for resident use. LPA interviewed staff which revealed the city did not have boil orders or water line issues, the facility did not receive any residents complaints about the water and residents have a drinking water dispenser for residents use. LPA observed residents using the drinking water dispenser during the visit. Based on the lack of evidence this allegation is 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: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2