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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608186
Report Date: 11/01/2022
Date Signed: 11/01/2022 04:10:30 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
10/28/2022 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221028151644
FACILITY NAME:YA YA'S HOUSEFACILITY NUMBER:
197608186
ADMINISTRATOR:ARGIRI BRATAKOSFACILITY TYPE:
740
ADDRESS:942 S. EVANWOOD AVENUETELEPHONE:
(626) 502-1690
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:6CENSUS: 4DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Via phone Crystal Galvan and Mariano Fabian in person. TIME COMPLETED:
04:19 PM
ALLEGATION(S):
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Facility is experiencing financial hardship.
INVESTIGATION FINDINGS:
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LPA was greeted by caregiver Mariano "Jun" Fabian and was put on the phone with Administrator Crystal Galvan and LPA discussed the purpose of the visit.
LPA toured the facility with Caregiver Mariano and checked the food supplies and there was 2-day perishable and 7 days un-perishable food at facility. PPE supplies for 30 days was observed.
The investigation consisted of interviews with Administrator and 2 staff S#1 – 2. and 4 residents R1- R4. LPA asked for and obtained personnel rosters, resident roster, hospice notices for 3 residents, 2 chase bank statements, one in name of facility and one in the name of Licensee, Chase mortgage statement. Monthly expense report with no itemizing and property deed.

Regarding allegation: Facility is experiencing financial hardship.
Administrator stated that her pay is always on time, 2 of 2 staff stated that their pay is always delayed. Mortgage Payment paid last month was late and included a late fee. Facility could not provide proof of itemized list of expenses or 3 months cash reserves required to operate a RCFE facility.

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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-20221028151644
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: YA YA'S HOUSE
FACILITY NUMBER: 197608186
VISIT DATE: 11/01/2022
NARRATIVE
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The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated


Deficiency cited (please see 809D for details)


Exit interview conducted via phone with administrator Crystal Galvan and Caregiver Mariano signed the report with prior authorization from Administrator.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221028151644
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: YA YA'S HOUSE
FACILITY NUMBER: 197608186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited
CCR
87213
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87213 - The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements.

This requirement was not met as evidenced by
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Licensee will provided financial plan that conforms to the requirements of section 87155 and provide detailed itemized list of monthly expenses and proof that Licensee has at least 3 months of operating funds available at all times. Licensee will send proof to LPA by POC date.
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During the visit conducted on 11/01/22, LPA interviewed Staff members #1 through 2 and learned that there is an ongoing issue with Staff receiving their payroll on time. Staff are supposed to be paid twice a month on the 5th and 20th of the month, but facility has trouble guaranteeing the funds for payroll each payday. Also, Mortgage payment for month of October was late and included a late fee. Facility does not have adequate record keeping showing monthly expenses and balance (-$29.97) in the bank(s) is not sufficient to provide 3 months operating expenses based on the mortgage obligation alone.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3