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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200880
Report Date: 01/24/2024
Date Signed: 01/24/2024 01:24:08 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
01/23/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240123093405
FACILITY NAME:ARIZONA CARE HOMEFACILITY NUMBER:
019200880
ADMINISTRATOR:VALENCIA-GARCIA, LALLIEFACILITY TYPE:
735
ADDRESS:33051 ARIZONA STTELEPHONE:
(510) 489-2465
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
01/24/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lallie Valencia-GarciaTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained an injury
INVESTIGATION FINDINGS:
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On this day at around 10:45am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct investigation on the above allegation and met with the Administrator Lallie Garcia-Valencia and informed her about the purpose of the visit.

During the visit, LPA interviewed staff and reviewed records. Based on Client 1 (C1) Dangerous Propensities Record, C1 displays self injurious behaviors. C1 picks at skin or pounds thighs. Based on Daily Consumer Notes dated January 15, 2024, S1 heard C1 screaming at around 12:30 am. S1 checked on C1 and observed C1 skin picking with blood on C1's fingers. S1 did first aid on the wound and offered C1 crackers and tea to calm C1 down. C1 eventually went back to sleep.

The Administrator states the Union City Police Department conducted a welfare check on C1 on 1/23/2024
per Report#240123005. The Administrator states she informed the police officer about C1's skin picking
behavior. The officer also physically checked on C1. continuation on Lic 9099C






Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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 15-AS-20240123093405
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: 01/24/2024
NARRATIVE
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The Administrator states she offered the police officer additional documents that show C1's skin picking behavior but the officer states he has sufficient documents for the report which will be available in two weeks.

While at the facility, Anna Marie Galay, Behavior Analyst for the facility came. The behaviorist confirmed with LPA that C1 has history of skin picking behavior. The purpose of her visit is to address the latest skin picking incident.

Based on interviews and record reviews conducted, 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.




SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2