019200880-10-12-2023-15-AS-KHOS-CWPJRW-20231017071725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200880
Report Date: 10/12/2023
Date Signed: 10/12/2023 05:19:00 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, 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
10/05/2023 and conducted by Evaluator Luisa Fontanilla

COMPLAINT CONTROL NUMBER: 15-AS-20231005152154

FACILITY NAME:	ARIZONA CARE HOME		FACILITY NUMBER:	019200880
ADMINISTRATOR:	VALENCIA-GARCIA, LALLIE		FACILITY TYPE:	735
ADDRESS:	33051 ARIZONA ST		TELEPHONE:	(510) 489-2465
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 1	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Rosanna Refulgente		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not accepting resident back after hospitalization.

INVESTIGATION FINDINGS:

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On this day at around 9:45 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrive unannounced to conduct investigation on the above allegation. LPA met with staff Leanne Laca and Joemar Lagunte. LPA spoke with Administrator Lallie Garcia on the telephone and informed her about the purpose of the visit.
Administrator arrived at the facility at around 10:30 am.

During the course of investigation, LPA conducted interviews and record reviews. Client 1(C1) was on a trial stay at the facility to determine if C1 is a good fit from September 25 - October 5, 2023. On 9/30/2023, C1 sneaked out of the facility without staff knowledge. S1 who was opening the door noticed C1 run out of the home. C3 who was at the facility dropping off some items also witnessed C1 ran away. Staff tried to convince C1 to go back as it is not safe. C1 continued walking towards Alvarado Niles Rd/ I880 freeway. Staff called 911 and the police was able to take C1 back to the facility.
***continuation on Lic 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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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Control Number 15-AS-20231005152154

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: ARIZONA CARE HOME	FACILITY NUMBER: 019200880
	VISIT DATE: 10/12/2023

NARRATIVE

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Once the police left the facility, C1 started destroying properties. C1 became aggressive towards staff and other client. C1's Father was notified and requested the facility to call 911 for C1. C1 was put on a 5150 hold and was taken to John George Hospital.

On 10/1/2023, Administrator states she got a call from the hospital. The nurse was asking for information regarding C1 for assessment. Administrator states she provided the nurse details of the incident as well as C1's Father and CM contact information. Administrator denied being informed by the nurse that C1 was getting discharged that day.

Later during the day, Administrator states C1's Father sent her a text message saying that C1 is getting discharged and that he is not able to take C1 back home for C1 mother's safety.
Administrator states C1's Father was made aware by CM that if during trial period, things don't work, C1 will need to go back to his home.

While at the facility, LPA spoke with C1's Father who confirmed that C1 is back to their home since 10/4/2023. He states that C1's behavior is very unpredictable. He added that RCEB is still looking for a new home for C1 although it may take awhile. He also said the next home should be a locked one.

LPA interviewed CM during the visit. CM confirmed with LPA that C1 was placed at the facility on a temporary placement. And that C1's Father was made aware that if C1 is not a good fit for the facility, C1's Father needs to take C1 back home.

A review of C1's admission agreement confirms that C1's trial period is from 9/25-10/5,2023. However, the signed admission agreement indicates the requirements for eviction as specified in Sec 80068.5 Eviction Procedures.

Based on interviews conducted and records review, the above allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There is no deficiency noted.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

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