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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198202216
Report Date: 08/02/2022
Date Signed: 11/18/2022 05:13:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Pamela Bunker
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220512094013
FACILITY NAME:PAPILLON VILLAGEFACILITY NUMBER:
198202216
ADMINISTRATOR:SORIANO, MILAGROS B.FACILITY TYPE:
735
ADDRESS:2063 28TH STREETTELEPHONE:
(323) 731-3277
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:6CENSUS: 1DATE:
08/02/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Milagros SorianoTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident not being provided adequate food service.
Facility not clean.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, November 08, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensee Milagros Soriano. LPA Bunker explained the purpose of today's visit.
*** This amended Complaint Investigation Report LIC9099 & LIC9099-C dated 11/08/2022, superseded the original complaint report dated 08/09/2022**
The investigation consisted of the following: During the course of the investigation LPA Bunker interviewed staff 1-3 (S1-S3). S1, S2, S3, and LPA Bunker toured the facility. We observed an ample supply of perishable and non-perishable foods. S1 stated clients are served three (3) meals per day plus snacks S1-S3 stated clients get plenty of food to eat. S1-S3 stated when clients come home from their Day Program or work clients are allowed to eat and food is served seven days a week from Sunday-Saturday. During the tour of the home, it was not very cluttered and there was no carpet on the floors.
See continued LIC9099-C page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
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 11-AS-20220512094013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PAPILLON VILLAGE
FACILITY NUMBER: 198202216
VISIT DATE: 08/02/2022
NARRATIVE
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Continued LIC812-C page 2

Allegation #1: Resident not being provided adequate food service
Staff 1-3 (S1-S3) interviewed stated they had two clients and currently have one client and both clients were provided adequate food service. S1-S3 stated the clients are getting plenty of food to eat, three (3) meals per day plus snacks, breakfast, lunch, dinner, and snacks daily. LPA Bunker was unable to interview C1 he is non-verbal. S1-S3 stated the allegation is false.

Allegation #2: Facility not clean
Staff 1-3 (S1-S3) interviewed stated the facility is cleaned daily. We toured the facility and did not observe any cluttered. The entire facility has hardwood floors throughout the home. We did not observe any carpet on the floors. S1-S3 denied the allegation.

Investigation revealed the following: Staff 1-3 (S1-S3) interviewed stated the allegations are all false. LPA was informed by the administrator there is only one client currently in placement. C1 was at his adult day program and is nonverbal. The facility had plenty of meat, chicken, chicken patties, beef, steak, ground beef hamburger patties, pork, pork chops, fish, fish sticks, turkey, hot dogs, lunch meat, cold cuts, pizza, beans, peas, canned vegetables, fruit cups, peanut butter, milk, eggs, cheese, yogurt, bread, cereals, rice, noodles, pasta, potato, grain, crackers, nuts, chips, cookies, canned food, fresh fruits, fresh vegetables, sweets, desserts, juice, water, etc. LPA Bunker observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Staff 1-3 (S1-S3) interviewed stated the facility is cleaned daily. During the tour of the facility, there was no cluttered. The entire facility has hardwood floors throughout the home, and there was no carpet on any of the floors. The facility was clean, safe, sanitary, and in good repair at the time of the visit. S1-S3 denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 deemed unsubstantiated.

There were no deficiencies cited. Exit interview conducted.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20220512094013

FACILITY NAME:PAPILLON VILLAGEFACILITY NUMBER:
198202216
ADMINISTRATOR:SORIANO, MILAGROS B.FACILITY TYPE:
735
ADDRESS:2063 28TH STREETTELEPHONE:
(323) 731-3277
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:6CENSUS: 1DATE:
08/02/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Milagros SorianoTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not clean.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, November 08, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensee Milagros Soriano. LPA Bunker explained the purpose of today's visit.

*** This amended Complaint Investigation Report LIC9099 & LIC9099-C superseded the original complaint dated 08/09/2022**

The investigation consisted of the following: During the course of the investigation LPA Bunker interviewed staff 1-3 (S1-S3). S1, S2, S3, and LPA Bunker toured the facility. The home was not cluttered and there are hardwood floors throughout the facility. The facility appears to be clean. Allegation: Facility not clean. S1-S3 and LPA Bunker toured the facility. We did not observe any cluttered. The entire facility has hardwood floors throughout the home. We did not observe any carpet on the floors. See continued LIC9099-C page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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 11-AS-20220512094013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PAPILLON VILLAGE
FACILITY NUMBER: 198202216
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2022
Section Cited
CCR
80078(a)
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2
3
4
5
6
7
80087 (a) Buildings and Grounds:

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.

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2
3
4
5
6
7
The deficiency was corrected prior to today's visit.
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On 05/18/2022 LPA observed four (4) dining room chairs, sofa, and living room chair peeling, coming apart, and broken.

The violation poses a potential health and safety risk to residents in care.
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9
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14
Type B
08/02/2022
Section Cited
CCR
80087(a)
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2
3
4
5
6
7
80087 (a) Buildings and Grounds:

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.

LPA observed the kitchen floor. There were cracked and broken linoleum tiles.
1
2
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7
The deficiency was corrected prior to today's visit.
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On 05/18/2022, LPA Bunker observed the kitchen floor and it had cracks and broken floor tiles.

The violation poses a potential health and safety risk to residents in care.
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9
10
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12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20220512094013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PAPILLON VILLAGE
FACILITY NUMBER: 198202216
VISIT DATE: 08/02/2022
NARRATIVE
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3
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5
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13
14
15
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19
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21
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23
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25
26
27
28
29
30
31
32
Continued LIC812-C page 2

Allegation: Facility not clean
Staff 1-3 (S1-S3) interviewed stated the facility is cleaned daily. We toured the facility and did not observe any clutter. The entire facility has hardwood floors throughout the home. We did not observe any carpet on the floors. S1-S3 denied the allegation.

Investigation revealed the following: Staff 1-3 (S1-S3) interviewed stated the allegations are all false. LPA Staff 1-3 (S1-S3) interviewed stated the facility is cleaned daily. During the tour of the facility, there was no cluttered. The entire facility has hardwood floors throughout the home, and there was no carpet on any of the floors. The facility was clean, safe, sanitary, and in good repair at the time of the visit. S1-S3 denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 deemed unsubstantiated.

There were no deficiencies cited. Exit interview conducted.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5