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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800744
Report Date: 03/23/2022
Date Signed: 03/23/2022 02:28:10 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
03/18/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220318101614
FACILITY NAME:CASITAS ESPERANZAFACILITY NUMBER:
197800744
ADMINISTRATOR:JOSE GOMEZFACILITY TYPE:
772
ADDRESS:11925 1/4,1/2 11931 ELLIOTT AVTELEPHONE:
(626) 350-5304
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:13CENSUS: 11DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Shannon Steib - Program ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff confiscated client's mail
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Shannon Steve program manager and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested copies of client and staff roster. LPA Flores conducted a review of food supplies, interviewed staff #1,#2,#3,#4,#5 and client #1,#2,#3,#4,#5. LPA reviewed 5 client's files and requested copies of client #1,#2,#3,#4,#5's physician's report, admission agreement, client treatment plan and/or needs and care plan, acknowledgement of receipt of Notice of Privacy Practices, and Conservatorship communications. LPA Flores attempted to contact conservator for client #4.

The investigation revealed the following: Regarding allegation; Staff confiscated client's mail. It is alleged client's mail was recently confiscated by staff. Per Program Manager conservatorship has requested mail to be open and requestedto be retained if it's money or check with conservator prior to providing it to client #4. (CONTINUED ON LIC9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 5
Control Number 28-AS-20220318101614
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: CASITAS ESPERANZA
FACILITY NUMBER: 197800744
VISIT DATE: 03/23/2022
NARRATIVE
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Interviews with clients revealed, 3 out of 5 clients interviewed stated their mail/packages are provided to them seal or have open packages in front of staff to ensure there are no items that are inappropriate for clients. Interviews with staff revealed 2 out of 5 staff stated to check or open mail to ensure that there are no items that could be harmful, inappropriate, or per conservator request not to be provided to the clients. 2 out of 5 staff stated to not know whether packages/mail are open prior to being provided to the clients. 1 out of 5 staff stated packages are open by the clients in front of a staff to ensure there are no items that may be harmful or inappropriate for the clients. Documents reviewed revealed clients are able to manage their own cash resources and do not have special diets requested per a physician. Personal Rights signed by clients were observed on file.

Based on LPA's interviews and document review conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22,
Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Mark Rodriguez Director of Quality Assurance and a copy of this report, LIC9099D, and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/18/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220318101614

FACILITY NAME:CASITAS ESPERANZAFACILITY NUMBER:
197800744
ADMINISTRATOR:JOSE GOMEZFACILITY TYPE:
772
ADDRESS:11925 1/4,1/2 11931 ELLIOTT AVTELEPHONE:
(626) 350-5304
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:13CENSUS: 11DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Shannon Steib - Program ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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3
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9
Staff refused to offer client a special diet
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Shannon Steve program manager and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested copies of client and staff roster. LPA Flores conducted a review of food supplies, interviewed staff #1,#2,#3,#4,#5 and client #1,#2,#3,#4,#5. LPA reviewed 5 client's files and requested copies of client #1,#2,#3,#4,#5's physician's report, admission agreement, client treatment plan and/or needs and care plan, acknowledgement of receipt of Notice of Privacy Practices, and Conservatorship communications. LPA Flores attempted to contact conservator for client #4.

The investigation revealed the following: Regarding allegation: Staff refused to offer client a special diet. It is alleged client was refused for a reduced calorie diet. Interviews with clients revealed 3 out 5 clients stated to be provided alternative meals per request, and 1 out of the 3 stated to have a preference diet.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220318101614
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: CASITAS ESPERANZA
FACILITY NUMBER: 197800744
VISIT DATE: 03/23/2022
NARRATIVE
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2 out of 5 clients stated the food is good or could be better. Interviews with staff revealed 1 out 5 staff stated to be aware of 1 client having a preference diet. 2 out of 5 staff stated client's do not have a special diet, 1 out of 5 staff stated there is 1 client waiting to be refer for evaluation of special diet, and 1 out of 5 staff stated to not know about clients having special diet. LPA observed facility's food storage and observed sufficient food for 2 days worth of perishables and 7 days worth of non-perishables, which consisted of different meats, vegetables and fruits, breads, dairy, cereals, and variety of can foods. Documents reviewed revealed clients do not have special diets per physician or a request on file for client to follow a special diet. Admission agreement states in section 1. Basic General Services; c. Special diets only if prescribed by a doctor and documentation is provided.

Based on LPA's observations, document review, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Mark Rodriguez Director of Quality Assurance and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220318101614
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: CASITAS ESPERANZA
FACILITY NUMBER: 197800744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2022
Section Cited
CCR
81072(a)(20)
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81072 Personal RIghts: (a) Each client shall have personal rights which include, but are not limited to, the following:(20) To mail and receive unopened correspondence.

This requirement is not met as evidence by:
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Licensee will ensure residents rights are in place at all times, will provide personal rights training to staff, will update admission agreement plan of operation regarding mail policies and submit a copy of signing log, agenda to the department by 3/30/22.
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Based on interviews, and document review conducted licensee did not ensure residents were receiving unopened mail/packages which poses a potential risk to health, safety, or personal rights to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5