<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801621
Report Date: 05/17/2023
Date Signed: 05/17/2023 02:28:57 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
05/15/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20230515140442
FACILITY NAME:NCI AFFILIATES, INC-LINNEFACILITY NUMBER:
405801621
ADMINISTRATOR:TRACI M HOLLINGERFACILITY TYPE:
775
ADDRESS:496 LINNE ROADTELEPHONE:
(805) 238-6630
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:75CENSUS: 25DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Facility Lead / Lote RouseTIME COMPLETED:
02:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not address cockroach infestation on the facility grounds.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 At 11:45am on 05/17/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to investigate the allegation above to this complaint. LPA met with Facility Lead, Lote Rouse (S1) announced who he was and the reason for the visit.
S1 and LPA conducted a cursory tour of the facility. LPA did not observed any pest during the facility tour and observed the facility to be clean, safe, sanitary and in good repair. LPA conducted interviews of staff 1 though 7. S2 stated that they have seen one cockroach on 05/15/2023 in their classroom. S3 stated that they observed a small cockroach on 05/14/2023 in the kitchen but has not observed any other insects in the facility. S4 stated that they observed both cockroaches on 05/15/2023 and one on an unspecified date earlier in the month of May 2023. S5, S6, and S7 all stated they have not seen the two cockroaches or any other cockroaches at the facility. S1-7 all stated that the facility is always clean and in good repair. S1 presented documentation in a work order dated 05/15/2023 to address the two cockroaches observed by staff in May, additionally, Administrator Traci Holenger stated that they are calling Clark Pest Control this afternoon to satisfy the work order placed on 05/15/2023. CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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-20230515140442
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: NCI AFFILIATES, INC-LINNE
FACILITY NUMBER: 405801621
VISIT DATE: 05/17/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator also presented quarterly pest control invoices the show quarterly visits from Clark Pest Control as normal pest mitigation process for the facility. Do to the measures to keep the facility free of flies and other insects in the pest control contract, work order and scheduling of additional pest mitigation visits, there is not enough evidence at this time to support the allegation of, " Staff did not address cockroach infestation on the facility grounds.' and is unsubstantiated at this time.

Exit interview, report read, report singed, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2