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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191601613
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:56:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20230921095714
FACILITY NAME:WILMINGTON GARDENSFACILITY NUMBER:
191601613
ADMINISTRATOR:FLORES,V.ANDT.FACILITY TYPE:
735
ADDRESS:1311 WEST ANAHEIM STREETTELEPHONE:
(310) 835-6366
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY:48CENSUS: 40DATE:
09/26/2023
UNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Vic Jun FloresTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee does not ensure facility is free from pets.
Licensee does not ensure that facility is sanitary.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 09/26/2023, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint visit to deliver findings regarding the above allegations. LPA Richard met with Administrator Vic Jun Flores and explained the reason for the visit and later was joined by Licensing Program Manager (LPM) Ulysses Coronel

The investigation consisted of the following:
On 09/26/2023, LPA Richard and LPM Coronel toured the facility inside and out with administrator Flores.
LPA Richard reviewed and requested, staff and resident's records. LPA interviewed five (R1-R5) clients, and five staff (S1-S5). LPA Richard requested and reviewed and collected facility documents.

This report is cotinued, please see LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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 5
Control Number 11-AS-20230921095714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613
VISIT DATE: 09/26/2023
NARRATIVE
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The investigation revealed the following:

Regarding allegations: Licensee does not ensure facility is free from pests.

On 09/26/23, LPA interviewed staff S1-S5 about the allegation above, all 5 staff agreed the allegation is true, some of the clients room do have bedbugs. The staff also reported they have noticed bed bugs in residents room. LPA interviewed clients C1-C5 all clients stated they observed beg bugs at the facility. During today investigations LPM, LPA and Administrator observed bedbugs in Clients C1, C2 and C3. Based on Observation and interviews there are sufficient evidence to support the above allegation: There is a preponderance of evidence to prove violation did occur, therefore the allegation is substantiated.

Regarding allegation: Licensee does not ensure that facility is sanitary.

LPA interviews with clients C1-C5 indicate that clients bedrooms were unsanitary, during the investigation LPA observed stain on the bed sheets, the floor, the wall. Observed cigarettes butts, left over food in bedrooms. The water fountain in lobby and in the dining room had visible mold, stain, and calcium deposits surrounding the water faucet. About the allegation above all the staff agreed the allegations are true. LPA interviewed clients C1-C5, all clients stated the facility is in unsanitary condition. Based on Observation interviews there is sufficient evidence to support the allegation, There is a preponderance of evidence to prove the allegation violation did occur, therefore the allegation is substantiated.

Regarding allegations: Facility is in disrepair.

On 09/26/23, LPA observation and interviews staff S1-S5 about the allegation above all the staff agreed the allegation is true, some of the clients room do need repair, LPA observed the ceiling inside C3 bathroom have water damage and cracks.

Based on Observation interviews and records review there is sufficient evidence to support the allegation: There is a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is substantiated.

Deficiencies were cited.

Exit interview was conducted a copy a of the report and appeal rights were provided to Administrator Flores.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230921095714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds. The facility shall be clean,...for the safety and well-being of clients, employees and visitors.The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidenced by:
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The Administrator agreed to create a plan to address bedbugs from the facility. Proof of corrections will be submitted to antonine.richard@dss.ca.gov.
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Based on LPA observation and interviews conducted the Licensee failed to ensure the facility is free from bed bugs. During LPA visit, LPA observed Bed bugs in C1-C3 bedrooms. which poses a potential heath and safety risk to client in care.
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Type B
10/12/2023
Section Cited
CCR
85095.5(a)(2)(A-E)
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Infection Control Requirements , A licensee shall ensure that infection control practices are maintained as follows: Environmental...products. These activities shall be completed, at a minimum, as follows:..transmission. This requirement was not met as evidenced by:
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The Administrator agreed to create a plan to ensure that the facility is in sanitary condition. Proof of corrections will be submitted to antonine.richard@dss.ca.gov.
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Based on LPA observation and interviews conducted the Licensee failed to ensure the the facility is in sanitary condition. During LPA visit, LPA observed C1-C3 bedrooms and 2 water fountains were unsanitary, which poses a potential heath and safety risk to client in care.
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230921095714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILMINGTON GARDENS
FACILITY NUMBER: 191601613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
80087(a)
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Buildings and Grounds. The facility shall ...in good repair at all times for the safety and well-being of clients, employees and visitors.The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidenced by:
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he Administrator agreed to create a plan to address the facility shall be in good repair at all times. Proof of corrections will be submitted to antonine.richard@dss.ca.gov.
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Based on LPA observation and interviews conducted the Licensee failed to ensure the facility is in good repair. LPA observed the ceiling inside C3 bathroom have water damage and cracks, which poses a potential heath and safety risk to client in care.
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5