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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202713
Report Date: 10/19/2024
Date Signed: 10/19/2024 06:07:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210806153730
FACILITY NAME:RACHELLE'S HOME IFACILITY NUMBER:
445202713
ADMINISTRATOR:RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:99 AIRPORT BLVDTELEPHONE:
(831) 319-4190
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY:12CENSUS: 9DATE:
10/19/2024
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Magali EsquivelTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility not following COVID 19 screening protocols for visitors.
Staff spoke to resident inappropriately
INVESTIGATION FINDINGS:
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Allegation: Facility not following COVID 19 screening protocols for visitors.
Based on interviews and observation during the tour of the facility, the department observed COVID 19 screening protocols for visitors and staff. At the time of the complaint the facility was alleged to have not checked temperatures of staff or residents the department was unable to confirm or deny this based on the available infromation today.

Allegation: Staff spoke to resident inappropriately. All staff interviewed denied witnessing or speaking to any of the residents inappropriately. Staff interviewed stated that the residents are treated with respect and dignity.

The above allegations are unsubstantiated
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210806153730

FACILITY NAME:RACHELLE'S HOME IFACILITY NUMBER:
445202713
ADMINISTRATOR:RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:99 AIRPORT BLVDTELEPHONE:
(831) 319-4190
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY:12CENSUS: 9DATE:
10/19/2024
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Magali EsquivelTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility patio area unsafe.
INVESTIGATION FINDINGS:
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Allegation: Facility patio area unsafe.

During the tour of the facility with staff on 10/19/2024, LPA and staff observed ceramic roof tiles stored on the ground by the back fence, frames for patio furniture, a space heater, other miscellanous items. Based on these observations the department confirmed that the facilities' patio areas is unsafe and needs attention.

As a result of this investigation, LPA finds the allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview was conducted with Administrator.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20210806153730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: RACHELLE'S HOME I
FACILITY NUMBER: 445202713
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
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The facility will clean the area and submit photo evidence to the LPA to confirm that the area is clean and free of debris by POC date 10/31/2024.

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This requirement not met as evidenced by photos taken and observation. LPA and staff observed ceramic roof tiles stored on the ground by the back fence, frames for patio furniture, a space heater, other miscellaneous items.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3