500309303-10-6-2023-27-AS-SDOB-CWJM25-20231012091256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 500309303
Report Date: 09/28/2023
Date Signed: 10/06/2023 05:24:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230717130540

FACILITY NAME:	J & L GUEST HOME		FACILITY NUMBER:	500309303
ADMINISTRATOR:	ANITA NIEL		FACILITY TYPE:	740
ADDRESS:	237 S ABBIE STREET		TELEPHONE:	(209) 527-2765
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY:	32	CENSUS: 29	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Sarah Rico		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Consumer sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 09/28/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility house manager, Sarah Rico, who was requested by this LPA to go ahead and contact the facility designated Administrator, Renee Little, to inform her that CCL was present at this time.
Current census was 29 residents.
The facility designated Administrator, Renee Little, arrived shortly thereafter to this facility while this LPA was conducting this complaint visit.
The purpose of this visit was to deliver and present the findings of this investigation to this facility and it's representatives at this time.
Based on interviews and information gathered throughout the course of this investigation, it was learned that R1 would often get picked up and taken out of this facility from time to time by their loved ones. It was learned that while seated in the vehicle, R1 attempted to put on the seatbelt and had a hard time in doing so. It was learned that while R1 was wrestling with the seat belt in trying to pull it out far enough so that R1

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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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Control Number 27-AS-20230717130540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: J & L GUEST HOME	FACILITY NUMBER: 500309303
	VISIT DATE: 09/28/2023

NARRATIVE

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could insert the clip into the buckle, R1 was pushing up against the seat and thrashing around in the back seat. It was learned that it was difficult for R1 to locate the buckle and get the seat belt to click securely.
Based on interviews, these actions caused R1 to sustain bruises to the shoulder areas and parts of the arms. It was learned that this incident took place on the weekend away from this facility and the bruising did not show up until later on the week after returning to this facility.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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