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Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: C00046022 Site Location: 678 N WILSON WAY Account ID: AR0004629 <br /> Receivedby: EE0000025 SEDRA Received Date: 3/21/2018 Print Date: 3/21/2018 2:17:59PM <br /> Assigned To: EE0008999 HUYNH Assigned Date: 3/21/2018 <br /> Proorem/Element Code,1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint: <br /> 64 YEAR OLD COMPLAINANT ALLEGES THEY WERE AT FACILITY ON 3/19/2018 AT APPROXIMATELY 2:30 PM.COMPLAINANT ORDERED <br /> CHICKEN SALAD,APPROXIMATELY 1 V2 HOURS LATER BECAME ILL WITH SYMPTOM OF DIARRHEA.COMPLAINANT STATED THE <br /> FOLLOWING DAY WAS ILL WITH SYMPTOMS OF DIARRHEA,HEADACHE,ABDOMINAL PAIN,LOW GRADE FEVER AND CHILLS.DID NOT <br /> SEEK MEDICAL ATTENTON. <br /> Complaint Mode: p Complaint Mode Codes A-Agency Referral a-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> I-Intemet/Email S-Shedfrs Office <br /> ----------------------------- -------------------- <br /> PROPERTY <br /> ------------ ---- ---------- -- --- _------- —PROPERTY INFORMATION OWNER INFORMATION <br /> Facility:FA0002462-EL POLLO LOCO#3307 Owner OW0001417-NOR-CAL CHICKEN <br /> Site Location 678 N WILSON WAY STE 3 RP/DBA EL POLLO LOCO <br /> STOCKTON,CA 95205 RP Address 930 VIRGINIA AVE <br /> Cross Street EASTLAND MODESTO,CA 95350--515 <br /> Mailing Address: 2155 W.March Ln Ste. 1 A Billing Address 2155 W.March Ln Ste. IA <br /> Stockton,CA 95207 STOCKTON,CA 95207 <br /> Home Phone :209-942-2144 <br /> Phone :209-942-2144 EXT: Work Phone :209-589-3224 EXT: <br /> DisMct 001-VILLAPUDUA,CARLOS Location Code 01-STOCKTON <br /> APN 14129003 G'u <br /> Date Abated 3qZ/(- Inspector ID#: �N1 <br /> ry <br /> --- — '7 --- <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: <br /> Circle appropriate Status Code <br /> 01-Field Response-Violations Cited and Corrected 50-LEAD Assessment Performed-No Abatement Required <br /> 02-Office Response Only 52-LEAD Abatement Regired-See Program Record File <br /> 06-Violations Cited-see Linked PROGRAM FACILITY FILE 97-Disaster Planning and Response <br /> 07-ReHerred to Other Agency 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 08-Unable to Verify Alleged Complaint MN-EHD Monitoring Status <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File PD-Permit Issued-Pending Well Installation <br /> 11-Multiple Complaints-SEE ACTIVE CASE# RS-Resolved-New Well Installed <br /> 12-DA Referred Complaint-See Program Enforcement Action Form S1-Tank pumped <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# S2-Hooked up to public sewer <br /> 28-Alleged FBI-No Major Violations Identified S3-Septic system repaired <br /> 29-Alleged FBI-Major Violations Identified <br /> ompalnt Reviewed by: V S <br /> ^ ate: Updated by: ate: <br /> �o <br /> stns rm <br />