191221043-9-5-2023-28-AS-TVAO-CVLMFK-20230912093429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221043
Report Date: 09/05/2023
Date Signed: 09/05/2023 02:57:14 PM

Unsubstantiated

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
08/11/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230811124145

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:	09/05/2023
		UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Larissa Cantos - Caregiver		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not surrender resident's cash resources to resident upon eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Larissa Canto caregiver and delivered findings.

The investigation consisted of the following: On 8/17/23 LPAs Flores and Margaryan conducted a visit and interviewed Administrator, and staff #2 over the phone. LPAs requested a copy of staff/client roster, reviewed client #1 (C1)'s file, requested copies of admission agreement, physician's report, identification and emergency information, statement of account dated: 4/21/23, personal and incidental distribution sheet, invoice dated: 6/6/23. On 8/18/23 LPA received a breakdown of expenses for the month of May 2023. On 8/21/23 LPA received check stubs send to social security. On 9/5/23 LPA and social worker attempted to contact Social Security office.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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 28-AS-20230811124145

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: 09/05/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff did not surrender resident’s cash resources to resident upon eviction. It is alleged facility is client's payee, therefore social security (SSI) money is currently going directly to them leaving client without money for basic needs. Interview with C1 revealed, C1 has not been able to obtain funds as SSI has not change payee. Interview with administrator revealed, the facility follows SSI policy of returning the money directly to SSI once a client has left or is no longer at the facility. Per facility’s social worker after the client was evicted on 5/31/23, social worker assisted C1 with paying for a hotel room and other expenses through the month of June with C1’s SSI money as money was send to the facility. C1 and social worker went to SSI office in person to request update of payee to self. On 5/31/23 C1 was evicted an investigation was conducted on 7/13/23 regarding eviction on complaint # 28-AS-20230707111110. Document review revealed a check stub/invoice was signed by C1, which notes the sum of a total of $1550,(board and care for the amount of 1324.82 and personal and incidental (P&I) money for $225.63) were distributed to C1 and signed by C1 on 6/12/23. Record of Client's Safeguarded Cash Resources notes a balance of 225.63 for 6/1/23, C1 signed received on 6/1/23. On 8/18/23, An analysis of funds for June 2023 was provided. This analysis notes expenses on personal items at stores, food purchases, and motel payments for 5/31-6/9 and 6/19-6/26 for a total of $1775.63. Facility’s accounting department received direct deposit from SSI for C1 on 7/3/23 and 8/3/23. Accounting department send check #13949 dated 7/27/23 including a note that C1 is no longer the payee and check #14045 dated 8/4/23 to SSI returning C1’s money. Per documents review the facility follow steps to ensure C1’s money was return to SSI.

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

Exit interview was conducted with Katrin Silvestro Social Worker and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

LIC9099 (FAS) - (06/04)

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