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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413255
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:00:07 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2023 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20231204101736
FACILITY NAME:RANCH COUNTRY HOMEFACILITY NUMBER:
366413255
ADMINISTRATOR:MELROSE RAMOSFACILITY TYPE:
740
ADDRESS:4189 LEXINGTON AVETELEPHONE:
(909) 628-6999
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 5DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Staff Anita Tablit and Tita MateoTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to initiate a complaint investigation regarding the above allegation. Regarding the allegation that the facility has pest: LPA toured the facility with staff (S1) Anita Tablit and found the facility to be clean, free of odors and free of insects or pest. LPA inspected kitchen, opended drawers, cupboards and refrigerator and did not observe any roaches at time of inspection. S1 interviewed and stated that there was no observations of any roaches on the kitchen. Staff (S2) Tita Mateo interviewed and stated that there was no onservation of roaches in the kitchen. LPA did observe a can of roach spray stored in drawer under the kitchen sink. LPA did not observe any live to dead roaches in the kitchen.

****Continued on LIC 9099 C****
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
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 56-AS-20231204101736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: RANCH COUNTRY HOME
FACILITY NUMBER: 366413255
VISIT DATE: 12/05/2023
NARRATIVE
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LPA Prieto interviewed residents (R1, R2, R3, R4 and R5) and none were able to communicate if the facility has had a infestation of insects or pest. Administrator Melrose Ramos was unable to be communicated with at time of inspection. During today's inspection, LPA was not able to confirm that the facility has pest.

Based on the information obtained there is not enough evidence that the facility has pest. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by staff Anita Tablit and LPA Prieto and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2