075601514-1-10-2024-15-AS-YFLS-D2MUZ3-20240220150049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601514
Report Date: 01/10/2024
Date Signed: 01/10/2024 02:11:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/02/2024 and conducted by Evaluator Alona Gomez

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240102120656

FACILITY NAME:	PENNY'S GUEST HOME		FACILITY NUMBER:	075601514
ADMINISTRATOR:	GARDNER, JOSEFINA		FACILITY TYPE:	740
ADDRESS:	78 RYEGATE PLACE		TELEPHONE:	(925) 361-8781
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 4	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Josefina Gardner		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility has an infestation of cockroaches

INVESTIGATION FINDINGS:

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On 1/10/2024 at 12:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit to Administrator Josefina Gardner.

LPA toured the facility with administrator including but not limited to bedrooms, bathrooms, kitchen, and common areas. During tour LPA did not observeany live cockroaches.

During the 10-day complaint visit. LPA interviewed 2 staff. LPA requested copies of the following documents: pest control receipts.

Report continues on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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 15-AS-20240102120656

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PENNY'S GUEST HOME	FACILITY NUMBER: 075601514
	VISIT DATE: 01/10/2024

NARRATIVE

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When LPA spoke with S1 and S2 they stated that they have not seen any cockroaches and regularly have seen the facility get serviced by Orkin Pest Control for bugs. S1 informed LPA that they recall Orkin coming out last year to spray facility.

Administrator informed LPA that Orkin maintains the pesticide services to insure facility is bug free

No residents were available to interview.

LPA did observe bug sprays and one dead dry cockroach trapped behind the glass on the kitchen oven display.

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

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