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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320253
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:08:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/23/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20241023154303
FACILITY NAME:BEVERLY HOMES - LAWNDALEFACILITY NUMBER:
198320253
ADMINISTRATOR:CHIONG, BEVERLYFACILITY TYPE:
735
ADDRESS:4558 WEST 163RD STTELEPHONE:
(626) 389-7498
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY:4CENSUS: 4DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Celerina Matibag, StaffTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff do not provide nutritious meals to clients in care
INVESTIGATION FINDINGS:
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On 10/30/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Staff, Celerina Matibag and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:

On 10/30/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Staff, Celerina Matibag. LPA requested LPA Shirley received copies of the following: Staff Roster, Resident Roster, weekly menu, daily schedules, and reviewed clients facility file.

The investigation revealed the following:

Con'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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-20241023154303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BEVERLY HOMES - LAWNDALE
FACILITY NUMBER: 198320253
VISIT DATE: 10/30/2024
NARRATIVE
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Allegation: Staff do not provide nutritious meals to clients in care

On 10/30/24, LPA Shirley reviewed the weekly menus and found that they contained all important food groups. During interviews, LPA Shirley ask S-2 what are you planning to cook for dinner tonight? S-2 stated that she was cooking spaghetti. Per the weekly menu, on Wednesday, October 30th, facility is offering beef steak with gravy, steamed rice or mashed potatoes and mixed vegetables, which is a discrepancy in the answer that C-2 provided in her interview. Staff are not following the weekly menus. S-2 stated that the clients do not like the meals being provided. She stated that they prefer to eat fast food. S-2 stated that she offers alternative meals.



LPA Shirley interviewed staff-1 thru staff-3 (S-1 thru S-3). LPA asked, does staff provide nutritious meals to clients in care? Of those interviewed, 3 out of 3 answered yes. LPA interviewed Client-1 thru Client-4 (C-1 thru C-4). LPA asked, are you being provided a nutritious meal daily?” Of those interviewed, 4 out of 4 answered yes.

Based on interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20241023154303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BEVERLY HOMES - LAWNDALE
FACILITY NUMBER: 198320253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
80076(a)(1)
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80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This
requirement is not met as evidenced by:
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Administrator will review current weekly food menus and update selections according to the USDA Basic Food Group Plan and following that plan. Please submit copies of updated menu's for plan of correction to LPA Felisa Shirley's Attn by fax to 424-554-1016 or email to felisa.shirley@dss.ca.gov by POC due date of 12/2/24.


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Based on records review, LPA Shirley found that facility staff was not following weekly menus provided for October 2024. This is a potential health and safety risk to 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/23/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20241023154303

FACILITY NAME:BEVERLY HOMES - LAWNDALEFACILITY NUMBER:
198320253
ADMINISTRATOR:CHIONG, BEVERLYFACILITY TYPE:
735
ADDRESS:4558 WEST 163RD STTELEPHONE:
(626) 389-7498
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY:4CENSUS: 4DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Celerina Matibag, StaffTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide adequate activities to clients in care
INVESTIGATION FINDINGS:
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5
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On 10/30/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Staff, Celerina Matibag and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:

On 10/30/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Staff, Celerina Matibag. LPA requested LPA Shirley received copies of the following: Staff Roster, Resident Roster, weekly menu, daily schedules, and reviewed clients facility file.

The investigation revealed the following:

Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20241023154303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BEVERLY HOMES - LAWNDALE
FACILITY NUMBER: 198320253
VISIT DATE: 10/30/2024
NARRATIVE
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Allegation: Staff do not provide adequate activities to clients in care

On 10/30/24, LPA Shirley reviewed all resident’s daily schedules, which includes walks in the community, church, recycling and day program. If they choose not to go to day program, there are activities in the home that are available to do, such as, Legos, watch TV, listen to radio, board games and to use the tablet. LPA Shirley observed C-1 engaged in an activity on the floor in the living room upon arrival to this facility. C-2 does recycling on his own. He brings home the items that he collects at the day program and on his way home.

LPA Shirley interviewed staff-1 thru staff-3 (S-1 thru S-3). LPA asked, does staff provide adequate activities to clients in care? Of those interviewed, 3 out of 3 answered yes. LPA interviewed Client-1 thru Client-4 (C-1 thru C-4). LPA asked, are you given adequate activities during the day?” Of those interviewed, 4 out of 4 answered yes. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not provide adequate activities to clients in care,” therefore the allegation is unsubstantiated.

A copy of this report is being signed by staff, Celerina Matibag to be given to the Administrator, Jesus Chiong.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5