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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801344
Report Date: 11/27/2023
Date Signed: 11/27/2023 11:05:40 AM

Unsubstantiated


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
06/22/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230622150551
FACILITY NAME:VICTORIA HOMEFACILITY NUMBER:
197801344
ADMINISTRATOR:MARIA ALVARADOFACILITY TYPE:
735
ADDRESS:14002 MANSA DRIVETELEPHONE:
(562) 921-0543
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:4CENSUS: 3DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Maria AlvaradoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff retaliated against resident.
Illegal eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 11/27/23 regarding the above allegations. LPA Ramirez was met by Administrator Maria Alvarado and explained the purpose of the visit.

The investigation consisted of the following: Initial complaint investigation was conducted on 6/27/23 by LPA Trueman and needs further investigation was required. LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Client Roster (LIC 9020), Staff #1 - 2 interviews(S1 – S2), Client #1 interviews (C1), attempted interview of Client#2 (C2), Witness #1 interview(W1) copies of Client #1 (C1): Identification and Emergency Information, Physician’s Report dated 10/16/2023, Victoria Home Quarterly Progress Report dated 10/19/2023 and 05/09/2023, Letter requesting relocation dated 05/25/23 and physical plant tour.

See 9099-C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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 2
Control Number 28-AS-20230622150551
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: VICTORIA HOME
FACILITY NUMBER: 197801344
VISIT DATE: 11/27/2023
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff retaliated against resident- It is alleged facility staff retaliated against resident. Two (2) out of the two (2) staff interviewed deny this allegation. Due to cognitive impairment of client#2 (C2), LPA was unable to interview client regarding allegation. Interview with C1 did not corroborate allegation. 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.

Illegal Eviction- It is alleged C1 was illegally evicted from the facility. LPA Ramirez toured facility and observed C1 sitting in living room area, waiting to be picked up by C1’s day program. LPA Ramirez requested C1 to give LPA tour of C1’s room. LPA observed C1’s personal belongings in two (2) dresser cabinets and in a closet. LPA Ramirez reviewed a “Special Request for Relocation” addressed to East Los Angeles Coordinator (ELARC) dated 05/25/2023 and indicates C1’s requires a higher level of care and the facility will continue to provide care to C1 until relocation occurs. Letter addressed to ELARC did not indicate eviction but, request to relocate. Two (2) out of the two (2) staff interviewed deny this allegation. Due to cognitive impairment of client#2 (C2), LPA was unable to interview client regarding allegation. Interview with C1 did not corroborate allegation. 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.

Exit interview conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
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