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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290706
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:37:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/19/2022 and conducted by Evaluator Ashley Calderon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221019101414
FACILITY NAME:HAMILTON HOUSEFACILITY NUMBER:
191290706
ADMINISTRATOR:PETERSON, JANICEFACILITY TYPE:
735
ADDRESS:739 W. GLENOAKS BLVD.TELEPHONE:
(818) 502-9188
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY:11CENSUS: 8DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth Caballero- DSPTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility rooms are dirty
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Calderon initiated a complaint investigation for the allegation listed above. LPA Calderon met with DSP worker, Elizabeth Caballero and explained the purpose of todays visit.

The investigation consisted of the following: LPA Calderon conducted a tour of the phsycial plant with Caballero. LPA Calderon observed living room area, kitchen area, laundry area, 7 resident bedrooms, 3 bathroom, staff office room and attached gargae. LPA Calderon interviewed staff and residents, collected pest control cleaning preperation guidelines, Pest Company Elimination Treatment Plan, email confirmation of measurements taking place due to bed bugs, pictures of bed bug bites from residents, R2 phsycian report will be sent to LPA due to bed bug bites, and LPA took pictures of the residents rooms.

Continue on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
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 5
Control Number 28-AS-20221019101414
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706
VISIT DATE: 10/27/2022
NARRATIVE
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Regarding the allegation of : Facility rooms are dirty, alleged rooms are direty and cluttered. LPA Calderon interviewed 4 staff, 3 were done telephonically and one in person. S1 and S2 stated residents clean their own rooms. S1 stated "residents do cleaning on their own and don't want staff to clean it." Based on interviews with residents 7 out of 9 residents stated they clean their own bedrooms. R8 stated that everyone has their own chores to do around the house. 6 out of 8 residents stated staff provide cleaning supplies, staff just direct and tell residents how to clean and what is needed to be done but they do their own cleaning. LPA Calderon observed rooms are in unsanitary conditions Room #1,2,4,5,6 (RM) and took pictures.

Based on interviews conducted with facility staff, facility residents, documentation gathered and LPA observations, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 6 on Personnel Requirements are being cited on the attached LIC 9099D.

Exit interview was conducted with Myrna Stevenson. A copy of the report and appeal rights were provided DSP worker.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/19/2022 and conducted by Evaluator Ashley Calderon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221019101414

FACILITY NAME:HAMILTON HOUSEFACILITY NUMBER:
191290706
ADMINISTRATOR:PETERSON, JANICEFACILITY TYPE:
735
ADDRESS:739 W. GLENOAKS BLVD.TELEPHONE:
(818) 502-9188
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY:11CENSUS: 8DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth Caballero- DSPTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility not taking appropriate measures to eradicate bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Calderon initiated a complaint investigation for the allegation listed above. LPA Calderon met with DSP worker, Elizabeth Caballero and explained the purpose of todays visit.

The investigation consisted of the following: LPA Calderon conducted a tour of the phsycial plant with Caballero. LPA Calderon observed living room area, kitchen area, laundry area, 7 resident bedrooms, bathroom, staff office room and gargae. LPA Calderon interviewed staff, residents, regional office Quality Assurance, collected pest control cleaning preperation guidelines, Pest Company Elimination Treatment Plan, email confirmation of measurements taking place due to bed bugs, pictures of bed bug bites from residents, R2 phsycian report will be sent due to bed bug bites, and LPA took pictures of the residents rooms and laundry room.

Continue on 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20221019101414
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706
VISIT DATE: 10/27/2022
NARRATIVE
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The investigation revealed the following: Regarding allegation of Facility has bed bugs. alleged facility is not taking appropriate measures to eradicate bed bugs and stop the spread. LPA Calderon and Caballero conducted a tour of the physical plant and observed rooms of residents are free of bed bugs on mattresses. LPA observed residents clothing are all out of the rooms and are in plastic bags outside in the detached garage. LPA Calderon interviewed staff and 3 out of 4 started that on 10/15/22 staff was aware of bed bug infestation.1 out 4 staff stated they were aware of bed bug issue on 10/17/22. S4 stated and provided email documentation with Stanley Pest Control from 10/19/22 about the findings to confirm bed bug at the above home and that the company provided preparation guidelines and discussed treatment plan. During staff interviews S1, S3 and S4 stated Stanley Pest Control did not have facility scheduled for an appointment when S4 called to confirm on 10/25/22 and S1 stated S1 was aware and S1 arranged another company to perform treatment for bed bugs on 10/26/22. 10/30/22 R2 saw physician for bed bugs bites. Receipts collected shows that the facility has been treated for pest -bed bugs. Facility Human Resource Depart will call the Environmental Health Department to report bed bugs.

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.

An exit interview was held with Myrna Stevenson , a copy of the reports were provided and appeal rights were given.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20221019101414
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
CCR
85065(c)
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(c) The licensee shall employ support staff as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.
The requirement is not met as evidence by:
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LPA Calderon explaned telephonically to Carlos Correa that In-Service Training to be done in regards to sanitary conditons and responsibility to clean and perform house cleaning duties. Meeting to be held about House Rules of staff performing cleaning duties. Plan of Care Due date: 10/18/22
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Based on interviews, and observations the licensee did not ensure to keep facility in sanitarty conditions. Licensee should employee staff to perform house cleaning.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5