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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800744
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:35:31 PM

Unsubstantiated


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
04/05/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220405114355
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:
05/24/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Shsnnon SteibTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff failed to meet resident's medical needs
Facility is understaffed
Resident missed multiple medical appointments
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Shannon Steib and explained the reason for the visit.
The purpose of the visit is to deliver the findings from the original complaint dated 04/05/2022.
The initial visit was conducted on 04/12/2022 and included the following:
At 9:15 AM Interim Program Director Mark Rodriguez was interviewed.
At 10:00 AM S 1 was interviewed. Resident and Staff Rosters were submitted.
Client's 1-5 were interviewed from 10:20 AM to 11:30 AM.
In regards to the allegation Staff failed to meet resident's medical needs, based on interviews conducted and information gathered it was revealed by Staff S1 that Conservator for Client 1 was asking for physician's approval and once received it was to be scheduled. Said he is on schedule.
Staff S 2 stated that Client 1 had just gotten cleared for the booster for those over 50.
Conservator for Client 1 stated it is true that he told facility they need authorization 1st from physician in order to get 2nd booster. Stated he is following Public Guardian procedures to get court approval.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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 4
Control Number 28-AS-20220405114355
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: 05/24/2022
NARRATIVE
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Booster test was scheduled for 04/21/2022.
Booster shot administered on 04/24/2022.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
In regards to the allegation Facility is understaffed ,staff interviewed stated that there is sufficient staff with there being 3 staff, plus director and counselor.
At visit conducted on 04/12/2022 LPA observed that there were sufficient staff with 5 staff on shift.
Client's interviewed stated that there is enough staff to help everyone and they are professional and respectful.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
In regards to the allegation Resident missed multiple medical appointments. based on interview with client 1 he stated that he hasn't missed any of his appointments. Stated that staff carry out their duties and are respectful.
Conservator interviewed stated that Client 1 has completed all appointments with physician, podiatry and eye doctor.
Staff interviewed stated that eye doctor appointment was completed 04/05/2022, orthopedic appointment completed 04/26/2022 and medical doctor was seen on 01/14/2022, 02/01/2022 and 04/21/2022.
It should be noted that pre-placement appraisal dated 08/04/2021 is checked off no glaucoma.
Physician's Report dated 1/14/2022 is checked no for visual impairment.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/05/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220405114355

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:
05/24/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Shannon SteibTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility failed to provide appropriate transportation for residents
INVESTIGATION FINDINGS:
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In regards to the allegation Facility failed to provide appropriate transportation for residents, based on interview with Conservator for Client 1 he stated that there were appointments that were rescheduled because there was not transportation available. Stated that sometimes staff may call off especially during Covid and transportation may not be available on a certain day.
Stated that the facility did reschedule the appointments properly.
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.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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 4
Control Number 28-AS-20220405114355
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: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2022
Section Cited
CCR
80075(a)
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Health Related Services. The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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The licensee will provide written statement. Indicating that moving forward, facility will ensure that the medical and dental appointments as well as follow ups will be completed in timely manner.
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This requirement is not met as evidenced by; the facility client #1 (C1) had an appointment with eye doctor and the staff did not take C1 to the scheduled appointment because transportation was not available This poses an immediate health, safety risk to the clients 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4