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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800830
Report Date: 05/22/2025
Date Signed: 05/22/2025 12:21:22 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
05/16/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250516125450
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: DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maria Corona, Back up to AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit at the facility above. LPA met with Maria Lopez Back up to Administrator and explained the purpose of the visit.

LPA De Leon requested the following records: Resident 1's (R1) Preplacement Appraisal, Admission Agreement, LIC 602 Physicians Report, Appraisal Needs and Services Plan, and Resident Personal Property and Valuables.

LPA interviewed staff at 9:50am, 10:00am, and 10:30am. LPA interviewed Resident at 11:00am.
LPA toured Room 11 where R1 resides and took photographs of R1's side of the room.

On the allegation: Staff did not safeguard resident's personal items. LPA interviewed Staff, residents and R1's records at the facility, Staff stated that R1 losses or misplaces things daily and most of the time the staff are able to help R1 find what R1 is looking for. Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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-20250516125450
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: 05/22/2025
NARRATIVE
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 R1 has left R1's cell phone in the dining area or set down in the TV area and staff have been able to locate it and return it to R1. R1 said there are no items of R1's currently missing. R1 does not feel the staff take R1's items but feels some of the residents may do it just to get a kick out of it because an item goes missing then once R1 complains the item turns up. The facility has helped R1 get two lock boxes with keys that only R1 has possession of so R1 can keep R1's things locked up. R1 has a room mate and R1 does not think R1's roommate takes anything. R1 did bring up a few things about people that live out of the facility that R1 feels takes R1's items, LPA explained to R1 if that is the case R1 needs to report that to the police department because it is not the facility staff or residents involved. LPA observed R1's room in be in disarray with things out everywhere, R1 has a lock box with a key for R1's valuables and currently R1 is not missing anything. R1 said R1 had a piece of mail delivered on Monday that has not been given to R1, staff said they give the mail to the residents as soon as it comes in, staff confirmed R1 did not have anything delivered Monday to the facility. The Administrator is going to sit down with R1 , confirm the company has the correct address to mail it to R1 and help get R1's mail resent out to be delivered to the facility. Based on the lack of evidence and R1 has no items currently missing this allegations 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: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2