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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191591995
Report Date: 03/05/2026
Date Signed: 03/05/2026 05:01:18 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
03/03/2026 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260303120211
FACILITY NAME:PTL GUEST HOMEFACILITY NUMBER:
191591995
ADMINISTRATOR:BELEN A.CONNOLYFACILITY TYPE:
735
ADDRESS:7112 HALRAY AVE.TELEPHONE:
(562) 698-1608
CITY:WHITTIERSTATE: CAZIP CODE:
90606
CAPACITY:6CENSUS: 3DATE:
03/05/2026
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Willfredro "Willy" Garcia - Live-In CaregiverTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not ensure facility was free from pests
Staff does not ensure the facility is clean
Staff are not documenting medications appropriately
Staff did not ensure medications were kept in the original packaging
Staff are not following the approved program design
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Willfredo Garcia and explained the purpose of today's visit, shortly after Rosario "Cherrie" Garcia (caregiver) arrived to assist with visit.

The investigation consisted of the following:

LPA toured facility, conducted a medication review for all 3 clients, observed facility sketch located in dining area, interviewed 3 Staff (S1-S3) and 2 Clients (C1-C2).

(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
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 6
Control Number 28-AS-20260303120211
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: PTL GUEST HOME
FACILITY NUMBER: 191591995
VISIT DATE: 03/05/2026
NARRATIVE
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The investigation revealed the following:
Allegation: Staff did not ensure facility was free from pests
It is alleged that there have been droppings of rodents within client drawers, closets and bed linens that indicate recent rodent activity. LPA toured facility and observed multiple mouse/rat traps throughout the home, in kitchen, bedrooms and bathroom. LPA observed rodent droppings on kitchen floor and in room #1 (closet, under bed, and in dresser). LPA interviewed 2 clients and each confirmed the above allegation, clients stated they have not seen any rodents within the last month. LPA interviewed 3 staff and each confirmed the allegation and stated that they have not seen any new rodent activity within the last couple of months. Interview with S3 confirmed that in October they caught a rat in the kitchen area. Interview with S1 confirmed that Regional Center has issued a Corrective Action Plan (CAP) for this and they have since hired an exterminator to ensure there are no insects or rodents in the facility.

Allegation: Staff does not ensure the facility is clean


It is alleged that the facility is excessively cluttered and has accumulated dust throughout multiple areas of the home. LPA toured facility and did not observe excessive dust or clutter within the home, however, during tour of the exterior and patio area, LPA observed the area to be excessively cluttered, the activity/patio area was filled with boxes, wagons, scooters and different items, leaving the outdoor activity/patio area inaccessible for clients. Interviews with 3 staff confirmed that Regional Center conducted a visit and addressed this incident and staff has since cleaned area, and continue to clean and de-clutter weekly.

Allegation: Staff are not documenting medications appropriately


It is alleged that staff are signing for medication on the MAR when medication is not at the facility. LPA conducted a medication review and observed that the MAR is not being documented properly as creams for C1 and C3 are being refused by clients, the are is empty with no signatures, instead of being documented as a refusal. Interview with S1 revealed that during a visit with Regional Center it was observed that S2 was signing that they administered medication to client when medication had been discontinued, medication was not administered and proof of medication was provided, however, S1 had accidentally signed the MAR.

Allegation: Staff did not ensure medications were kept in the original packaging


It is alleged that staff are removing medication from original packaging and placing in plastic containers for the next morning’s medication distribution. Per interview with S1 it was confirmed that during a visit with Regional Center it was observed that S2 had pre-packaged the next days medication in a separate container, S1 stated that they have spoken to S2 about this previously and since this visit they have conducted an in-service training on medication administration. LPA interviewed S1 and it was confirmed that this incident did occur, they have since been retrained and understand that they cannot pre-package medications. (Continued on LIC9099-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20260303120211
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: PTL GUEST HOME
FACILITY NUMBER: 191591995
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2026
Section Cited
CCR
80072(a)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidence by:
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Administrator/Licensee stated that Regional Center has issued a Corrective Action Plan for this and they have already hired an exterminator to ensure facility is free from rodents/pests. Administrator/Licensee to email copies of the invoices to LPA and clean out areas with rodent droppings by POC due date. tena.herrera@dss.ca.gov
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During tour LPA observed multiple rat/mouse traps located in kitchen and bedrooms. Rodent droppings were observed on kitchen floor and in the dressere drawers, closet and under bed of room 1. Interviews with 2 clients confirmed rats have been seen, interview with 2 staff also confirmed rats were present at facility.
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Type A
03/05/2026
Section Cited
CCR
80075(k)(5-6)
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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers. This requirement was not met as evidence by:
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Licensee/Administrator to email a copy of the in-service that was held on medication administration along with participant names and signatures to LPA by POC due date. tena.herrera@dss.ca.gov
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During interviews it was confirmed by Licensee/Administrator that when Regional Center conducted a visit on 1/27/26 it was observed that S1 had prepackaged the next mornings medication in a seperate container.
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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: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20260303120211
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: PTL GUEST HOME
FACILITY NUMBER: 191591995
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2026
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence by:
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Licensee/Administrator to clear the outdoor patio/activity area so that the area is clean, safe, sanitary at all times for the safety and well-being of clients, employees and visitors and submit photo proof of area to LPA via email by POC due date. tena.herrera@dss.ca.gov
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LPA observed the area to be excessively cluttered, the activity/patio area was filled with boxes, wagons, scooters and different items, leaving the outdoor activity/patio area obstructed by the items and inaccessible for clients.
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Type B
03/12/2026
Section Cited
CCR
80070(a)
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80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidence by:
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Licensee/Administrator stated they have already conducted an in-service training for this as Regional Center had conducted a visit and issued a CAP for this same issue. A copy of the In-Service training and participant list to be emailed to LPA by POC due date. tena.herrera@dss.ca.gov
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During medication review LPA observed that cream for C1 (Cloberasol 0.05%) and cream for C3 ( Ketoconazole 2%) are being refused by clients and staff are not properly documenting MAR with refusals, additionally interview with Licensee/Administrator revealed that S2 had been documenting that they were administering medication to a client that had been discontinued.
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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: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20260303120211
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: PTL GUEST HOME
FACILITY NUMBER: 191591995
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2026
Section Cited
CCR
80022(k)
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80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. This requirement was not met as evidence by:
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Licensee/Administrator to provide the addendum that was recently created and provided to regional center that indicates Room #4 is designated for live in staff, to LPA via email by POC due date. tena.herrera@dss.ca.gov
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During interview with Administrator/Licensee it was confirmed that per the original Plan of Operation/Program Design there was nothing noted that there would be a room utilized for a live-in staff, it was also confirmed there are two live in staff (S2 & S3) that occupy bedroom 4 near patio, which LPA toured during visit.
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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: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20260303120211
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: PTL GUEST HOME
FACILITY NUMBER: 191591995
VISIT DATE: 03/05/2026
NARRATIVE
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Allegation: Staff are not following the approved program design
It is alleged that the facilities original program design does not indicate that they will be any live-in staff, and there is a live-in staff in one room with personal belongings stored in the garage. During facility tour LPA observed there is a Staff bedroom in the back area of the facility. S2 and S3 both live in the facility and both verbally stated that they live in the facility during interview. The facility sketch located in the dining area was observed to have the Staff Room listed. Interview with S1 confirmed that they originally did not indicate on the program design that there will be a live in staff but have since revised the program design to include a staff bedroom. S1 stated that Regional Center issued a CAP for this as well and they have already made the necessary corrections with them, LPA informed S1 that the revision should have also been sent to licensing.


Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC9099D pages.

Exit interview was held, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6