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Gam) Complaint Investigation Form Report*5104 <br /> COMPLAINT ID: C00034637 Site Location: 3201 W BENJAMIN HOLT DR STE 1E AccountlD AR0001793 <br /> Received by: EE0001785 NESBY Received Date: 2/14/2012 Print Date: 2/14/2012 4:45:53PM <br /> Assigned To: EE0000149 BORGES Assigned Date: 2/14/2012 <br /> Program/Element Code.1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint., <br /> (C)STATES CAUGHT A CASE OF FOOD BORNE ILLNESS AFTER EATING AT THE RESTAURANT. INCIDENT OCCURRED AROUND 6:15 ON <br /> 2/13/12.SYMPTOMS OF NAUSEA AND VOMITING. <br /> Complaint Mode. P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> I-Internet/Email S-Sheriffs Office <br /> — <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0001793-CASA FLORES Owner: OW 0012778-CRUCES FLORES LLC <br /> Site Location 3201 W BENJAMIN IIOLT DR STE 155 RP/DBA CASA FLORES <br /> STOCKTON,CA 95219 RP Address 9028 BRIDALVEB.CIR <br /> Cross Street STOCKTON,CA 95212 <br /> Mailing Address: 3201 W BENJAMIN HOLN DR STE#155 Billing Address 9028 BRIDALVEIL CIR <br /> STOCKTON,CA 95219 STOCKTON,CA 95212 <br /> Home Phone :209-993-5326 <br /> Phone :209451-1116 Work Phone :209451-1116 <br /> Distncl 002-RUHSTALLF.R,LARRY Location Code 01 -STOCKTON <br /> APN 10017009 <br /> Dale Abated a I— Inspector ID#: <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: ?— <br /> Circle appropriate Status Code <br /> 01-FIELD ABATED 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 02.OFFICE ABATED 50-LEAD Assessment Performed-No Abatement Required <br /> 03-NAI SENT 52-LEAD Abatement Regired-See Program Record File <br /> 04-NOTICE TO ABATE ISSUED 97-Disaster Planning and Response <br /> 05-DA-ENFORCEMENT ACTION INITIATED 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 06-EHD FACILITY-see Linked PROGRAM FACILITY FILE CL-Case Closed <br /> 07-REFERRED TO OTHER AGENCY <br /> 08-UNABLE TO VERIFY <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 12-DA Referred Complaint-See Violation Tracking Fonn <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 28-FOODBORNE ILLNESS-No Major Violations Identified <br /> s104sot <br />