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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607576
Report Date: 11/23/2021
Date Signed: 11/23/2021 04:15:29 PM



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 DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2021 and conducted by Evaluator Jey Cardenas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211117134340
FACILITY NAME:C-H #4 RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
197607576
ADMINISTRATOR:FISHER, ADLEANFACILITY TYPE:
740
ADDRESS:12137 RAMONA AVETELEPHONE:
(562) 630-8123
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:4CENSUS: 3DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Staff#1TIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility license is not posted in a location that is accessible to public view.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced 10 day initial complaint visit to the above facility to initiate complaint investigation. Upon arrival at the facility, LPA met with staff#1 and explained the purpose of today’s visit. LPA conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection.

The investigation consisted of the following: LPA interviewed staff#1 (S1), and attempted to interview three (3) residents who were present at the time of visit, LPA toured physical plant.
Regarding allegation: Facility license is not posted in a location that is accessible to public view. On 11/23/21 LPA asked to see facility license, LPA asked S1 if staff knew where the license was located; S1 was unsure and contacted Miss Woods via telephone. Miss Woods guided S1 to the license. LPA was lead to the laundry space, which is located towards the middle of the property; the laundry has a door to close behind. LPA observed that license was posted on a bulletin mounted on the wall in the laundry area. Unless one went into the laundry area, public wouldn’t be able to see it; therefore the license is not
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 11-AS-20211117134340
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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: C-H #4 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607576
VISIT DATE: 11/23/2021
NARRATIVE
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accessible to public view.

Based on LPA’s observations the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.
Exit interview conducted copy of this report and copy of appeal rights provided to facility representative
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20211117134340
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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: C-H #4 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607576
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2021
Section Cited
CCR
87113
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Posting of License -The license shall be posted in a prominent location in the licensed facility accessible to public view. This requirement not met as evidenced by: On 11/23/21 LPA Cardenas observed license posted behind closed door in the laudry area,
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LIcense shall be posted in a prominet location inside the facility, accessible to view.
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License is not accessible to public view. This poses a potential personal rights risk to residents 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.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3