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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601262
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:34:51 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
03/08/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220308145636
FACILITY NAME:SHANNEN GUEST HOMEFACILITY NUMBER:
015601262
ADMINISTRATOR:DE LUNA, DIOSDADOFACILITY TYPE:
740
ADDRESS:5727 RUNNING HILLS AVENUETELEPHONE:
(925) 980-1087
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 5DATE:
03/11/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Diosdado De Luna, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility is not following COVID-19 protocols.
INVESTIGATION FINDINGS:
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On 3/11/2022 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrator, Diosdado De Luna and informed him reason for the visit.

During the course of investigation, LPA interviewed 2 staff and reviewed COVID-19 screen documents (visitor's log, temperature log). Upon entry, staff did not conduct COVID-19 screening for LPA. Interview with staff indicated that staff did not check visitor's vaccination status prior to visit.

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 LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
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 15-AS-20220308145636
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: SHANNEN GUEST HOME
FACILITY NUMBER: 015601262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:
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Administrator has agreed to conduct training to all staff regarding current guidelines for screening visitors and submit staff sign-in sheet & training materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not following CCLD screening guidelines for visitors 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2