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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802765
Report Date: 11/30/2022
Date Signed: 11/30/2022 02:42:48 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
09/23/2020 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200923151215
FACILITY NAME:LARKS ADULT RESIDENTIAL FACILITY #3FACILITY NUMBER:
197802765
ADMINISTRATOR:LARKS, ANNA MARIEFACILITY TYPE:
735
ADDRESS:3045 FRONT ST.TELEPHONE:
(626) 281-3548
CITY:ALHAMBRASTATE: CAZIP CODE:
91803
CAPACITY:4CENSUS: 3DATE:
11/30/2022
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Peter Lacsina - CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Clients P & I funds were not available for inspection during visit.
Smoke detector is in disrepair.
Hardwood floors are deteriorating.
Kitchen walls are greasy.
Mattresses are worn and have stains on them.
Broken drawers in the facility making them difficult to open.
Facility not providing resident with hygiene supplies.
Expired food item found in refrigerator.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Peter Lacsina and explained the reason for the visit.

The investigation consisted of the following: On 10/05/2020, LPA Katrdzhyan conducted an initial complaint visit via telephone interviews with the Administrator and Community Services Specialist from Eastern Los Angeles Regional Center (ELARC) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). Today’s visit, LPA Mora obtained copies of the client and staff rosters, interviewed Administrator, Staff 1 - Staff 2 (S1 – S2), Client 1 - Client 3 (C1 – C3) and Eastern Los Angeles Regional Center (ELARC) Community Services Specialist, and toured the facility.

(CONTINUED TO LIC 9099C)

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
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 6
Control Number 28-AS-20200923151215
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: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765
VISIT DATE: 11/30/2022
NARRATIVE
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The investigation revealed the following: regarding the allegation "clients P & I funds were not available for inspection during visit”, it is alleged that the clients' P & I funds were not available for inspection nor were the records of their cash resources because the administrator had them off-site to do calculations. Administrator and staff interviewed did not denied the allegation and stated this issue was corrected about 2 years ago. Clients interviewed could not corroborate the allegation due to intellectual disabilities. During today’s visit, LPA observed that the client’s P & I funds were locked at the facility.

Regarding the allegations “smoke detector is in disrepair”, “hardwood floors are deteriorating”, “kitchen walls are greasy”, and “broken drawers in the facility making them difficult to open”, it is alleged that some of the drawers in the facility were broken making them difficult to open, facility's hardwood floors are deteriorating, the walls in the kitchen were greasy, and there was a smoke detector that was beeping and needed the battery to be replaced. Administrator and staff interviewed did not denied the allegations and stated these issues were brought up to their attention and have been corrected about 2 years ago. Clients interviewed could not corroborate the allegation due to intellectual disabilities.Pictures confirming these allegations taken in September 2020 were provided to the LPA. During today’s visit, LPA observed that all smoke alarms were working, hardwood floors were replaced and in good conditions, kitchen walls were clean, and all drawers were in good condition.

Regarding the allegations “mattresses are worn and have stains on them”, “facility not providing resident with hygiene supplies” and “expired food item found in refrigerator, it is alleged that the mattresses were old, worn and had stains on them, there were no hygiene products to be found in the clients' bathroom except for a single toothbrush and no hygiene products were found anywhere else in the facility, and there was expired salad dressing in the refrigerator. Administrator and staff interviewed did not denied the allegations and stated these issues were brought up to their attention and have been corrected about 2 years ago. Clients interviewed could not corroborate the allegation due to intellectual disabilities. Pictures confirming these allegations taken in September 2020 were provided to the LPA. During today’s visit, LPA observed that all clients’ mattresses were replaced with new ones and have a cover to prevent stains on the mattresses, each client has a box with all necessary hygiene supplies in their bedrooms, and no expired foods were found in the refrigerator and kitchen.

Interview with ELARC Community Services Specialist revealed that all these allegations were resolved, and no health and safety issues have been observed since the correction. (CONTINUED TO LIC 9099C)
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20200923151215
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: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765
VISIT DATE: 11/30/2022
NARRATIVE
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Based on LPA's interviews, records reviewed, and observations, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 and Chapter 6 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20200923151215
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: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2022
Section Cited
CCR
80026(j)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by:
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During today's visit, LPA observed the client's P&I fund at the facility and were locked.

Licensee will review section code 80026(j) and submit a statement that they understand and will continue to complied with this section code. POC will be submitted to CCLD by 12/07/22.
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Based on interviews, the licensee did not comply with the section cited above. During a regional center inspection visit the clients P&I funds were not at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/07/2022
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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During today's visit, LPA observed that these issues were already corrected.

Licensee will review section code 80087(a) and submit a statement that they understand and will continue to complied with this section code. POC will be submitted to CCLD by 12/07/22.
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Based on interviews and records reviewed, the licensee did not comply with the section cited above. Drawers in the facility were broken, hardwood floors were deteriorating, kitchen walls were greasy, and a smoke detector needed new batteries which poses/posed a potential health, safety or personal rights risk 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20200923151215
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: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2022
Section Cited
CCR
85088(c)(1)
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85088 Fixtures, Furniture, Equipment and Supplies (c) The licensee shall ensure provision to each client of the following furniture, equipment...(1) An individual bed.... maintained in good repair, and...a clean mattress and pillow(s).

This requirement is not met as evidenced by:
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During today's visit, LPA observed that this issue was already corrected.

Licensee will review section code 85088(c)(1) and submit a statement that they understand and will continue to complied with this section code. POC will be submitted to CCLD by 12/07/22.
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Based on interviews and records reviewed, the licensee did not comply with the section cited above. Facility had mattresses that were old, worn and had stains on them which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/07/2022
Section Cited
CCR
85088(c)(5)
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85088 Fixtures, Furniture, Equipment and Supplies (c) The licensee shall ensure provision to each client of the following...supplies necessary for personal care and maintenance of personal hygiene.
(5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.
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During today's visit, LPA observed that this issue was already corrected.

Licensee will review section code 85088(c)(5) and submit a statement that they understand and will continue to complied with this section code. POC will be submitted to CCLD by 12/07/22.
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This requirement is not met as evidenced by:

Based on interviews and records reviewed, the licensee did not comply with the section cited above. Facility did not have hygiene supplies for the clients which poses/posed a potential health, safety or personal rights risk 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20200923151215
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: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2022
Section Cited
CCR
80076(a)(7)
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80076 Food Services (a) In facilities providing meals...the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human comsumption...
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During today's visit, LPA did not observed any expired foods.

Licensee will review section code 80076(a)(7) and submit a statement that they understand and will continue to complied with this section code. POC will be submitted to CCLD by 12/07/22.
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This requirement is not met as evidenced by:

Based on interviews and records reviewed, the licensee did not comply with the section cited above. An expired bottle of salad dressing was in the refrigerator, which poses an immediate health, safety or personal rights risk 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6