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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507001908
Report Date: 05/13/2025
Date Signed: 05/13/2025 11:22:44 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250507153854
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:
05/13/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Guillermina ZepedaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not prevent a resident from threatening another resident in care.
INVESTIGATION FINDINGS:
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On 05/13/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Giullermina Zepeda and explained the purpose of the visit. The purpose of this visit was to inform the facility and it's representative that a complaint has been filed against it at this time.

Current Census was 28. A tour of the facility was conducted. During the course of the tour, LPA conducted staff and resident interviews and reviewed facility records.

Based on the interviews conducted during the course of this visit, it was admitted that R1 will threaten R2 with comments such as "Shut up, 'F' YOU. It was stated that this will happen from time to time and the facility staff have been notified however there have been no ramifications regarding R1's behavior towards R2. Based on the information gathered, staff did not prevent a resident from threatening another resident in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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
Control Number 27-AS-20250507153854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MODESTO GUEST HOME
FACILITY NUMBER: 507001908
VISIT DATE: 05/13/2025
NARRATIVE
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Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged. The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulation.

An exit interview was conducted, a copy of this report and appeals rights were provided to the facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250507153854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MODESTO GUEST HOME
FACILITY NUMBER: 507001908
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87468.1(a)(1)
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(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This is not met as evidenced by: Based on interview and record review, the facility did not ensure that R2 was accorded with dignity with their roommate.
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Administrator states that a plan will be put in place to ensure that R2 feels comfortable in their room. This plan shall be submitted to the LPA for review by POC date.
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It was admitted by staff that they are aware that R1 would make comments towards R2. This poses a potential health, safety, and personal rights risks to persons in care.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3