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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507001908
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:12:57 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, 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
02/28/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220228152227
FACILITY NAME:MODESTO GUEST HOMEFACILITY NUMBER:
507001908
ADMINISTRATOR:GUILLERMINA ZEPEDAFACILITY TYPE:
740
ADDRESS:1344 E. ORANGEBURG AVENUETELEPHONE:
(209) 571-0116
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:31CENSUS: 28DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH: Guillermina Zepeda, Administrator (AD).TIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff are speaking to resident in an inappropriate manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Albert Johnson visited the facility today to deliver findings for a complaint investigation for the allegation listed above. LPA spoke with Guillermina Zepeda, Administrator (AD).

Allegation: Staff are speaking to resident in an inappropriate manner.

Based on interviews conducted with 6 residents on 3/7/2022, 5 of 6 residents stated that the facility staff address them with respect and one residents confirmed that the staff usually address each resident with respect. LPA was informed by that resident about an incident that happened on or about 2/22/22, the Lead staff for the day was not speaking to them in an appropriate manner. LPA was informed by the resident that the incident was personal and involved using the bathroom in an area that was not intended to be used as a bathroom. Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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 27-AS-20220228152227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MODESTO GUEST HOME
FACILITY NUMBER: 507001908
VISIT DATE: 05/17/2022
NARRATIVE
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LPA was told by this resident that the "The Lead Staff questioned them about using the bathroom in this area of the building and it made them feel bad and a little embarrassed." LPA asked if the staff used bad words or called them names? The residents stated "No". LPA asked if there were any other issues with staff talking inappropriately toward residents. All residents interviewed denied that staff speak to resident in an inappropriate manner.

Based on information provided through interviews and records reviewed, these allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2