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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600354
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:00:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2024 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240722123621
FACILITY NAME:PENNY'S GUEST HOMEFACILITY NUMBER:
075600354
ADMINISTRATOR:EPIFANIA ANGECIAFACILITY TYPE:
740
ADDRESS:1760 AYERS ROADTELEPHONE:
(925) 330-3086
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Epifania Angcla, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not allow authorized representative to view the menu
INVESTIGATION FINDINGS:
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On 7/29/2024 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPA met with caregiver, Aproniana Gionson and informed her of the reason for the visit. Administrator, Epifania Angcla arrived 30 minutes later.

During the course of investigation, LPA interviewed 2 resident, 2 staff, and complainant. Interview with staff revealed that facility does not have a sample menu available.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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
Control Number 15-AS-20240722123621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PENNY'S GUEST HOME
FACILITY NUMBER: 075600354
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87555(b)(6)
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General Food Service Requirements. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available...
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Administrator has agreed to create a sample menu and provide a copy to CCLD by POC date.
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This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not maintaining a sample menu which poses a potential health and safety risk to the 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2024 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240722123621

FACILITY NAME:PENNY'S GUEST HOMEFACILITY NUMBER:
075600354
ADMINISTRATOR:EPIFANIA ANGECIAFACILITY TYPE:
740
ADDRESS:1760 AYERS ROADTELEPHONE:
(925) 330-3086
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Epifania Angcla, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
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9
Staff are not serving food of quality to meet the residents need
INVESTIGATION FINDINGS:
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On 7/29/2024 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPA met with caregiver, Aproniana Gionson and informed her of the reason for the visit. Administrator, Epifania Angcla arrived 30 minutes later.

During the course of investigation, LPA interviewed 2 resident, 2 staff, and complainant. LPA observed facility had a variety of food items which included vegetables, eggs, dairy, breads, meat, and other items. Residents' lunch included salad, sandwiches, and watermelon. Interview with residents revealed the quality of food is okay and there's enough food for residents.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3