191221043-7-13-2023-28-AS-TVAO-CUXT8F-20230822143013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221043
Report Date: 07/13/2023
Date Signed: 07/13/2023 12:31:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230707111110

FACILITY NAME:	HOMES FOR LIFE FOUNDATION WILSON HOUSE		FACILITY NUMBER:	191221043
ADMINISTRATOR:	LIESS, CAROL		FACILITY TYPE:	735
ADDRESS:	54 N. WILSON AVE		TELEPHONE:	(626) 568-3657
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	8	CENSUS: 8	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Lerisa Cantos - Facility Manager		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Lerissa Cantos and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of staff/client roster. LPA interviewed 5 clients (C2- C6) and 5 staff (S1-S5), 3 staff were contacted over the phone. LPA reviewed client #1 (C1)'s file and requested copies of the following documents: eviction letter dated 5/8/23, behavioral contract dated: 5/5/23, appraisal/needs and service plan dated: 5/3/23, incident report dated: 5/6/23, physician's report dated: 5/10/22, identification and emergency information, admission agreement dated: 2/1/19 and 1/1/23, and staff logbook notes.

(CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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 3

Control Number 28-AS-20230707111110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOMES FOR LIFE FOUNDATION WILSON HOUSE	FACILITY NUMBER: 191221043
	VISIT DATE: 07/13/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Illegal Eviction. It is alleged on 5/31/2023 when C1 returned to the facility, manager did not allow C1 into the facility due to eviction and C1 did not received a formal eviction notice. On 5/6/23 facility contacted police department for assistance due to C1 breaking the glass on client's room after kicking it and showing unusual behaviors. Pasadena Police Department came out and arrested C1 due to an outstanding warrant instead as facility did not press charges against C1. On 5/18/23 administrator submitted a copy of eviction letter to the department. LPA Flores reviewed the letter and contacted facility's nurse to inquired about the date the letter will be serve to the client. Nurse advice LPA that the letter will be provided to C1 at the jail during a visit. LPA advice over the phone, the letter has to have the date it is given to the client and the 30 day starts that day. On 5/23/23 Facility's Nurse and Social worker attempted to visit C1 at jail and were not allowed. They were informed C1 was in the medical unit and not receiving visitors at the time. Staff inquired about delivering the letter to which they were informed they could not do that at the time. On 5/24/23 Social worker contacted Jail's nurse via email and was requested to contact via telephone to schedule a visit to deliver documents at the jail. On 5/31/23 C1 arrived at the home and facility's manager stated during the interview that C1 was not allowed into the home per administrator's instructions due to the eviction. Interviews with clients revealed 5 out of 5 clients interview had knowledge of eviction procedures. 5 out of 5 staff stated there were attempts made to provide the letter to C1. However, the letter was not physically handed to C1. Per interviews with staff due to C1 being in the medical unit the staff was not able to deliver the letter. Document review revealed a copy of eviction letter was on C1's file dated 5/8/23. No postage, signature of receipt, or refusal to sign was found in C1's file. Staff logbook note dated: 5/31/23 notes C1 arrived at the house and social worker spoke to C1 about administrator's instructions and assisted C1 with temporary shelter and obtaining personal items.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 6 are being cited.

Exit interview was conducted with Katrin Silvestro and a copy of this report, LIC 9099D, and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230707111110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOMES FOR LIFE FOUNDATION WILSON HOUSE	FACILITY NUMBER: 191221043
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/14/2023 Section Cited CCR 80068.5(a)	1 2 3 4 5 6 7	80068.5 Eviction Procedures (a) Except for children's residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following reasons: This requirement is not met as evidency by:	1 2 3 4 5 6 7	Administrator will schedule in-service training from a qualify source for all staff including administrator on Eviction Procedures by POC due date 7/14/23 and will submit a copy of training topic, duration, and sign-in log to the department by 7/20/23.
	8 9 10 11 12 13 14	Based on interviews and documents review licensee did not ensure C1 was provided a written 30 day notice before not allowing entrance to the facility which poses an immediate risk to the health, safety, or personal rights of the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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