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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600250
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:16:29 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
01/04/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240104132132
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL MONTEREY PARKFACILITY NUMBER:
198600250
ADMINISTRATOR:JENNIFER PICHINTEFACILITY TYPE:
735
ADDRESS:435 DE LA FUENTE STTELEPHONE:
(626) 289-2320
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY:4CENSUS: 4DATE:
01/05/2024
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Mohammed Shirazi, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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The facility is in despair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit to investigate the above allegation. LPA met with DSP Alex Chento and discussed the purpose of the visit. Administrator Mohammed Shirazi arrived a short time later and assisted with the visit.

LPA reviewed and obtained copies of staff and client rosters. LPA interviewed four staff S#1-S#4. LPA was unable to interview 4 clients due not being able to answer questions.
The investigation revealed:

Allegation: The facility is in despair. It is alleged that the facility is in disrepair and below are the details:

(Continue on 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
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 4
Control Number 28-AS-20240104132132
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: KAISER SPECIALIZED RESIDENTIAL MONTEREY PARK
FACILITY NUMBER: 198600250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2024
Section Cited
CCR
80087(a)
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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.

This requirement is not met as evidenced by
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Numbers #1-#4 have been cleared. Numbers #5-#9 need to be taken care of by POC date and proof sent to LPA In form of photos and/or invoices.
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1) Two Small holes with screws in C1 room that need repair.
This was already addressed and repaired at time of visit.
2) The blind in C4 room was replaced.
This was already addressed and repaired at time of visit.
3) The rail handle on the ramp is rusted.
The rust was removed, and rail handle is painted at the time of visit.

4) Mold in both bathrooms and hallway.
This was addressed and taken care of by time of visit.
5) Cracks and uneven cement on the ramp driveway and backyard.
Some of the work has begun on this but due to recent rain it was not completed, and repairs are pending.
6) Sofa broken and in need of replacement. Dining Chairs need to be replaced.
The sofa and chairs are still in living room and need to be replaced.
7) Broken tiles in the family and dining room. LPA observed floor tiles in at least 4 different areas that are cracked and need to be repaired or replaced. Facility should check under the sofa to make sure that tiles are in good repair when it is removed. Also, one tile on the fire place is loose and need to be repaired or replaced.
8) The inside of the facility needs paint job.
The facility has been painted inside and out but there are still some areas inside by the bathroom that need repair and painting.
9) Damaged trim in the front of the house and may be due to termites. Outside trim of the house needs to be fixed and painted.
Which pose/poses health or safety risk to persons in care.
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CCR
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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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20240104132132
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: KAISER SPECIALIZED RESIDENTIAL MONTEREY PARK
FACILITY NUMBER: 198600250
VISIT DATE: 01/05/2024
NARRATIVE
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(CONTINUE)

1) Two Small holes with screws in C1 room that need repair.

2) The blind in C4 room was replaced.

3) The rail handle on the ramp is rusted.

4) Mold in both bathrooms and hallway.

5) Cracks and uneven cement on the ramp driveway and backyard.

6) Sofa broken and in need of replacement.

7) Broken tiles in the family and dining room.

8) The inside of the facility needs paint job.

9) Damaged trim in the front of the house and may be due to termites.

LPA interviewed Administrator S1 and three other staff and took a tour of the entire home, inside and out. Administrator and 3 staff all stated some repairs are complete and some are pending. LPA observed the following:

1) Two Small holes with screws in C1 room that need repair.

This was already addressed and repaired at time of visit.

2) The blind in C1 room was replaced.

This was already addressed and repaired at time of visit.

3) The rail handle on the ramp is rusted.

The rust was removed, and rail handle is painted/repaired at the time of visit.

(CONTINUED)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20240104132132
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: KAISER SPECIALIZED RESIDENTIAL MONTEREY PARK
FACILITY NUMBER: 198600250
VISIT DATE: 01/05/2024
NARRATIVE
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4) Mold in both bathrooms and hallway.

This was addressed and taken care of by time of visit.

5) Cracks and uneven cement on the ramp driveway and backyard.

Some of the work has begun on this but due to recent rain it was not completed, and repairs are pending.

6) Sofa broken and in need of replacement. Dining Chairs need to be replaced.

The sofa and chairs are still in living room and need to be replaced.

7) Broken tiles in the family and dining room. LPA observed floor tiles in at least 4 different areas that are cracked and need to be repaired or replaced. Facility should check under the sofa to make sure that tiles are in good repair when it is removed. Also, one tile on the fireplace is loose and need to be repaired or replaced.

8) The inside of the facility needs paint job.

The facility has been painted inside and out but there are still some areas inside by the bathroom that need repair and painting.

9) Damaged trim in the front of the house and may be due to termites. Outside trim of the house needs to be fixed and painted.

During the complaint investigation, LPA measured the water, and it was measured at 125.9 in the bathroom. Also, there is a staff room adjacent to room 4 that is not on the facility sketch. Both issues are addressed on Case Management 809 and 809D.

Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Deficiencies are being cited on the attached LIC 9099D.

Exit interview and copy of report and appeal rights provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4