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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607476
Report Date: 06/22/2022
Date Signed: 06/24/2022 01:45:06 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
06/25/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200625164650
FACILITY NAME:VISTA COVE AT ARCADIAFACILITY NUMBER:
197607476
ADMINISTRATOR:NOEMI BIELYFACILITY TYPE:
740
ADDRESS:601 SUNSET BOULEVARDTELEPHONE:
(626) 447-0106
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:0CENSUS: 0DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director of Resident Services, Jennifer Lan, RNTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Allegation #1: Uncleared adult working at the facility.

Allegation #2: Administrator falsified staff record.
INVESTIGATION FINDINGS:
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Licensing Program Analyst/Retired Annuitant (LPA/RA) Elizabeth Ponce Ceniceros made an unannounced visit to the facility and was greeted by Staff (Director of Resident Services, Jennifer Lan, RN). The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. However, the facility is under a new change of ownership, effective 02/17/21; therefore, LPA/RA Ceniceros will mail to (former) Licensee.

An Initial 10-Day virtual visit was conducted by LPA Bonnie Tao on 07/03/20 (via telephone) with (former) Administrator Neomi Biely due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. During the virtual, video conference call with Administrator Biely, LPA Tao conducted a virtual tour of the facility’s physical plant. LPA interviewed Administrator and Staff #6 (S6: Business Office Manager). LPA obtained copies of the LIC 500 and resident roster. LPA requested pertinent documentation (ADP Payroll Report for the month of June 2020 (5th and 20th pay periods), Facility Staff Work Schedule (June 2020), Personnel Records, and Employment Application for Staff #1, #2, #3, #4, #5 and #6. LPA Tao conducted a virtual interview with Staff #2: Maintenance Director (via Face Time) on 08/27/20.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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 3
Control Number 28-AS-20200625164650
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: VISTA COVE AT ARCADIA
FACILITY NUMBER: 197607476
VISIT DATE: 06/22/2022
NARRATIVE
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Regarding Allegation #1: this investigation revealed that (former) Administrator Noemi Biely hired Staff #2 (S2: Walter Biely, Sr., Maintenance Director) subject to a criminal background check for clearance or criminal record exemption that shall be obtained prior to employment. In addition, Administrator and Staff #2 admitted to LPA Bonnie Tao that he (S2) has been working at the facility (approximately) 1.5 years, effective 05/01/19. A review of the facility’s LIC 500 “Personnel Report” shows no documentation of Staff #2 associated to the facility and no personnel record maintained on file. A review of the Licensing Information System (LIS) Facility Personnel Report Summary (dated 06/30/20) shows no record or clearance status or association of Staff #2 to the facility.

Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of OTHER (CRIMINAL RECORD CLEARANCE): Uncleared adult working at facility is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and a citation issued (ref. LIC 9099D). This violation invokes an immediate civil penalty of $500.00 (Refer to LIC 421B). Civil Penalty Assessed.

Regarding Allegation #2: this investigation revealed that (former) Administrator Noemi Biely and Staff #2 admitted to LPA Bonnie Tao (on 08/27/20 - via Face Time) that S2 had been working at the facility (approximately) 1.5 years, effective 05/01/19 and being paid under Staff #7 (S7: Walter Biely, Jr., Maintenance) timekeeping. A review of the facility's payroll (via ADP) documented Staff #2 documenting work hours and being paid on the 5th and 20th of the months - based on S7's timekeeping records.



Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of FALSE STATEMENTS: Administrator falsified staff record is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the followinpayroll report from ADP for month of June 2020 (5th and 20th pay periods), staff work schedule,g deficiency has been observed and a citation issued (ref. LIC 9099D).

No exit interview was conducted as the facility closed its doors, effective 02/17/2021. A copy of the Complaint Report, Appeal Rights, and Civil Penalty were sent certified mail (via USPS) to the (former) Licensee.

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200625164650
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: VISTA COVE AT ARCADIA
FACILITY NUMBER: 197607476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2022
Section Cited
CCR
87355(b)
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CRIMINAL RECORD CLEARANCE: Prior to the Department issuing a license, the applicant, Administrator, and any adults (other than a client residing in the facility), shall have a criminal record clearance or exemption. The standard of evidence has not been met:
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Licensee/Administrator shall read Title 22, Section 87355(b) “Criminal Record Clearance” and send a written statement to CCLD by the POC date that the Licensee/Administrator will ensure all staff obtain a Criminal Record Background Clearance and are associated to the facility - prior to employment in the facility. Unclear persons cannot return to work until
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(Cont) based on evidence that Administrator and Staff #2 (Maintenance Director) admitted to LPA Bonnie Toa that Staff #2 had been working at the facility (approximately) 1.5 years, effective 05/01/19.
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(Cont) they are cleared and associated to the facility. Submit copy of Live Scan to CCLD/El Segundo ASC Regional Office no later than POC due date on 06/27/22 (within 24 hours).
Type A
06/27/2022
Section Cited
CCR
87533(e)(1)
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CRIMINAL RECORD CLEARANCE. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall – prior to working, residing or volunteering in a licensed facility: obtain a California clearance or a criminal record exemption as required by the Department. This standard has not been met:
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Licensee/Administrator shall read Title 22, Section 87355 “Criminal Record Clearance” and send a written statement to CCLD by the POC date that the Licensee/Administrator will ensure all persons requiring fingerprint clearances are fingerprinted and associated to the facility - prior to employment. Submit copy of Criminal Record Clearance Exemption form
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(Cont) based on evidence that Administrator and Staff #2 (Maintenance Director) admitted to LPA Toa that Staff #2 had been working at the facility (approximately) 1.5 years, effective 05/01/19.
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(Cont) to CCLD/El Segundo ASC Regional Office no later than POC due date on 06/27/22 (within 24 hours).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3