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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320092
Report Date: 08/02/2023
Date Signed: 08/02/2023 05:11:41 PM

Substantiated


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
07/27/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230727163632
FACILITY NAME:LIFESTYLE BOARD AND CAREFACILITY NUMBER:
198320092
ADMINISTRATOR:ANGELES, JENNYLYNFACILITY TYPE:
735
ADDRESS:149 EAST 235TH STREETTELEPHONE:
(562) 743-1037
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 4DATE:
08/02/2023
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Kim Manor TIME COMPLETED:
03:33 PM
ALLEGATION(S):
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Licensee did not follow proper eviction procedures for client.
INVESTIGATION FINDINGS:
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On 08/02/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complaint visit at this facility. LPA met with administrator Kim Manor. LPA explained the purpose of the visit is to investigation the allegation mentioned above.

Investigation consisted of the following: Interviews with staff #1 -#2 (S1-S2) and clients #1-#4 (C1-C4), a review of client #1 (C1's) Admission Agreement, Appraisal/Needs and Service Plan, Physician's Report, Medical and Dental Service, Medication, Daily Progress Notes, House Rules, and copy of a 30-Day Eviction Notice. A tour of the facility.

Evaluation Report continues LIC 9099
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
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 4
Control Number 11-AS-20230727163632
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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092
VISIT DATE: 08/02/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Licensee did not follow proper eviction procedures for client.

The details of the complaint stated client #1 (C1) was served with a 30-Day Notice to Vacate. The complainant contacted the Department and claimed that (C1) is not treated fairly and was issued a notice to vacate without following the proper procedures.

The Department interviewed staff #1 (S1) who admitted issuing a notice to vacate to (C1) for violating house rules, exceeding the level of care, and for the health and safety of clients in care. (S1) claimed the eviction notice was advised by (C1’s) social worker for the processing to relocate the client.

An interview with (C1) stated (C1) received an eviction notice dated 07/27/23 and reported that (C1) must vacate the group home by 08/27/23.

The facility issued the 30-day notice to vacate to (C1’s) family representative and to (C1) only. A copy of the Eviction Notice and supporting documents were not sent to Community Care Licensing (CCL) at the El Segundo Regional office in accordance with (S1). The facility did not mail or fax to the Department a copy of the 30-Day written notice within (5) days of giving the notice to the client. The facility did not allow for the Department to investigate the reason for the eviction under the provision of Sections as written in Title 22 Regulations Section 80068.5 Eviction Procedures. The notice was determined to be invalid. According to interviews and record reviews, the above allegation is supported by sufficient evidence.

Based on observation, interviews, and record reviews, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. According to California Code Regulations, Title 22 the deficiency issued is documented on LIC 9099-D.

An exit interview was conducted with Kim Manor and a copy of the report was provided along with appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20230727163632
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: LIFESTYLE BOARD AND CARE
FACILITY NUMBER: 198320092
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
80068.5(a)(e)(f)
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Eviction Procedures-(a) Except for children's residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more...reasons:(e) The licensee shall mail or fax to the Department a copy of the 30-day written notice in accordance...within five days of giving the notice...(f) Upon request of a client or his/her authorized representative or responsible person, the Department will investigate the reasons for the eviction...
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Licensee is to review Title 22 Regulaiton Section 0068.5, and resubmit a 30-Day Notice to Terminate for RO's approval by POC due date: 08/09/23.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensse failed to provide a written Notice of Eviction to CCL within 5 days. Licencee did not allow for the Department to investigate the reasson for the eviction. This violation poses a potential health and safety risks to residents 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
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