547206577-12-20-2021-24-AS-MHON-CA7MFN-20211230083434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547206577
Report Date: 12/20/2021
Date Signed: 12/20/2021 12:47:30 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, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2021 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20211210162942

FACILITY NAME:	DOMINGO HOME, THE		FACILITY NUMBER:	547206577
ADMINISTRATOR:	DOMINGO, WALTER OR FE		FACILITY TYPE:	740
ADDRESS:	2069 LINDA VISTA		TELEPHONE:	(559) 784-2762
CITY:	PORTERVILLE	STATE: CA	ZIP CODE:	93257
CAPACITY:	6	CENSUS: 3	DATE:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Fe Domingo, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
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9

Staff gave resident marijuana.

INVESTIGATION FINDINGS:

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2
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9
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13

On 12/20/2021, Licensing Program Analyst (LPA) M. Yang conducted an initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with the Fe Domingo, Administrator.

During the course of the investigation, the Department conducted interviews and toured the facility. R1 was unavailable be interviewed. LPA interviewed staffs.

Based on the interviews conducted on the allegation staff gave resident marijuana. The preponderance of evidence standard has not been met; therefore, the above allegation are found to be UNSUBSTANTIATED. Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

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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