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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434417125
Report Date: 10/11/2023
Date Signed: 10/11/2023 04:11:59 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230905092602
FACILITY NAME:VARGAS CAMACHO, MARIAFACILITY NUMBER:
434417125
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria Vargas CamachoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adult(s) residing in the home
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mel Matos conducted an unannounced follow-up complaint investigation and met with Maria Vargas Camacho, Licensee. Purpose of today's follow up complaint investigation: deliver investigation findings. The investigation of the complaint allegation listed above was conducted by LPA Matos. Based on interviews, record reviews, observations, and evidence gathered during the investigation process, it is concluded that although the allegation noted on this complaint may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

Exit interview conducted and report was reviewed with the Maria Vargas Camacho. No deficiencies issued. A notice of site visit was given and must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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