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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507001908
Report Date: 07/05/2022
Date Signed: 07/05/2022 04:28:49 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
05/04/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220504101912
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:
07/05/2022
UNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Guillermina ZepedaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not prevent resident from engaging in inappropriate behaviors with another resident

Staff did not prevent resident from making inappropriate comments towards another resident

Staff are not providing a comfortable environment for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arielle Pascua and Licensing Program Manager (LPM) Stephenie Doub conducted an unannounced facility visit to deliver compliant findings. LPA Pascua and LPM Doub met facility designated administrator, Guillermina Zepeda and explained the purpose of the visit.

Throughout the course of this investigation, LPA Pascua conducted interviews and reviewed facility documents.

Based on interviews conducted with 4 residents on 05/04/2022 and 07/05/2022, it was learned during 1 resident interview that another resident has been video recording him against his will and has talked to staff about it but nothing has been done to mitigate the issue. Administrator stated that they have observed resident with the phone only playing video games and does not believe that phone has a recording capabilites.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
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-20220504101912
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: 07/05/2022
NARRATIVE
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1 of the 4 residents denied any issues with residents. 2 of 4 residents were not reliable witnesses due to medical conditions.

Staff was also interviewed during this investigation. Staff stated that when there are any alternations between residents they respond with the appropriate means to mitigate the situation. Staff members also stated they try to get ahead of any alternations between any residents before an incident may happen and they are told to separate residents in separate areas of the facility when needed. Based on a resident interview, they confirmed that staff responds to any issues between residents in a timely 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.

A exit interview was conducted, and copy of this report given to the facility.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2