198320433-1-10-2025-11-AS-UCOL-DG2NG8-20250424102639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320433
Report Date: 01/10/2025
Date Signed: 01/10/2025 10:35:58 AM

Unsubstantiated

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
09/11/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240911112822

FACILITY NAME:	JEANNE JUGAN RESIDENCE		FACILITY NUMBER:	198320433
ADMINISTRATOR:	SABINA NAYBERG		FACILITY TYPE:	740
ADDRESS:	2100 SOUTH WESTERN AVENUE		TELEPHONE:	(310) 548-0625
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	86	CENSUS: 36	DATE:	01/10/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Gloriella Jara, Administrator		TIME COMPLETED:	10:56 AM

ALLEGATION(S):

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Facility does not ensure sufficient staffing to meet resident needs.
Staff does not ensure residents are provided a comfortable environment.

INVESTIGATION FINDINGS:

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On 01/09/25 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an unannounced, subsequent, complaint visit at the above-mentioned facility. CCLD was met by Gloriella Jara, Administrator (S9), and the purpose of the visit was explained.
The investigation consisted of the following:

01/09/25 CCLD staff interviewed two (2) staff (S7, S9) and requested and reviewed a personnel roster, updated 09/02/24, and staff roster(s) from the dates of 12/01/24 - 01/10/25. On 10/04/24 CCLD staff interviewed an additional four (4) staff (S3-S6) and six (6) residents (R1-R6) and acquired facility documents, which included in-service training and which ranged from 06/03/24 through 09/12/24 covering topics pertinent to caring for residents receiving services. On 10/03/24 CCLD staff interviewed two (2) staff and acquired facility documents, which included incoming administrator certificate and email communication(s) between CCLD and the above-mentioned facility.
Report continues, see LIC9099-C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240911112822

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: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 198320433
	VISIT DATE: 01/10/2025

NARRATIVE

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On 9/13/24 CCLD staff were met with Emmanuel Ruiz, Licensee, and CCLD obtained the following documents: Client’s roster, Personnel roster, Staff schedule, Shower schedule or change schedule and (R#1-R#5) Medication Administration Records-(MARs) for 3 months.
The investigation revealed the following:

Regarding the allegation, “Facility does not ensure sufficient staffing to meet resident needs.”, it has been alleged that the facility does not have sufficient overnight staffing ratios. CCLD staff interviewed six (6) residents and six (6) staff. Interviews revealed that five (5) out of six (6) residents and three (3) out of six (6) staff have denied the allegation has taken place. Record reviews have revealed that on 09/01/24, 09/07/24, 09/14/24, 09/21/24, and 09/22/24 there was one (1) overnight staff between the hours of 10:00PM – 06:00AM, with one (1) staff living on-site and on-call. On 01/09/25 CCLD staff further interviewed staff seven (S7) who has confirmed NOC shift has been covered by at least one staff member and also confirmed one (1) staff is on call through the evening. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation, “Staff does not ensure residents are provided a comfortable environment.”, it has been alleged that, during the month of August, the facility internal temperature was too high for residents in care. Record reviews did not reveal any health related incidents related to the increase in temperature. CCLD staff interviewed six (6) residents and six (6) staff. Interviews revealed that five (5) out of six (6) residents and five (5) out of six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There has been zero deficiencies cited during today’s visit. An exit interview was held with Gloriella Jara, Administrator (S9), and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC9099 (FAS) - (06/04)

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