<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600558
Report Date: 01/30/2026
Date Signed: 01/30/2026 12:53:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/23/2026 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260123081442
FACILITY NAME:PALS EINDELIJK EL MONTEFACILITY NUMBER:
198600558
ADMINISTRATOR:GLORIA GALLEGOSFACILITY TYPE:
775
ADDRESS:11645 MCBEAN DR.TELEPHONE:
(626) 279-1064
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:60CENSUS: DATE:
01/30/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Program Manager Ezekiel MesaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure to maintain complete/accurate records.
Facility did not ensure to have appropriate staffing to meet ratios.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Program Manager Ezekiel Mesa and explained the reason for the visit.
The purpose of the visit is a complaint visit to investigate the above allegations.
At today's visit LPA interviewed Program Manager Ezekiel Mesa and Staff S1- S2.
Interviews were conducted with Client's C1- C10.
Staff and Client Roster were submitted.
Documentation was reviewed regarding Individual Service Plan (ISP's) for the clients and for staff/client ratios for November 2025 and December 2025.
In regards to the allegation Facility staff did not ensure to maintain complete/accurate records, based on interviews conducted and information gathered it was revealed by Staff S1 who confirmed that there were a total of 17 client ISP's that were incomplete because it wasn't reviewed by the Board Certified Behavioral Analyst (BCBA) who is a contracted consultant. Stated that reports are submitted monthly for approval.
Program Manager Ezekiel Mesa also confirmed that there were 17 ISP reports that were incomplete having
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
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 3
Control Number 28-AS-20260123081442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PALS EINDELIJK EL MONTE
FACILITY NUMBER: 198600558
VISIT DATE: 01/30/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
not been reviewed by the behavioral consultant.
Documentation was reviewed from 2023-2025 and it revealed that 17 ISP's were incomplete having not been reviewed and signed by the Behavioral Consultant.
Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapters 1 and 6), are being cited on the attached LIC 9099D.

In regards to the allegation Facility did not ensure to have appropriate staffing to meet ratios based on interviews conducted and information gathered it was revealed by Staff S1 who confirmed that in the months of November 2025 and December 2025 there were multiple days where documentation specify 1 to 4 as the ratio and not 1 to 3 as requested by Regional Center.
Review of documentation for November 2025 and December 2025 there were multiple days where documentation specify 1 to 4 as the ratio and not 1 to 3 as required by Regional Center.
Program Manager Ezekiel Mesa confirmed that there were multiple days that it was documented 1 to 4 ratio in those months.
Staff explained that during those 2 months there is always coverage by 5 management staff who always fill in when there are employees calling off or leaving sick.
Interview with clients in which 9 out of 10 said the program has sufficient coverage and that managers will also assist them along with their job coach.
All stated staff treat them well and are very kind.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapters 1 and 6), are being cited on the attached LIC 9099D.

Exit interview conducted and copies provided to Program Manager Ezekiel Mesa.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260123081442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PALS EINDELIJK EL MONTE
FACILITY NUMBER: 198600558
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
CCR
82070(a)
1
2
3
4
5
6
7
Client Records
The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. A separate, complete, and current record shall be maintained at the program site for each client.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility to submit plan by the POC due date that involves the completion of client records by the Behavioral Consultant.

Plan submitted to Regional Center 01/22/2026.
Deficiency cleared.
8
9
10
11
12
13
14
Facility failed to ensure that client records were complete with 17 client files not reviewed by the Behavioral Consultant which causes a potential risk to clients in care.
8
9
10
11
12
13
14
Type B
02/06/2026
Section Cited
CCR
82065.5(a)(1)
1
2
3
4
5
6
7
Staff- Client ratio
Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met:
(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center.
1
2
3
4
5
6
7
Facility to submit plan by the POC due date that documents staff-client ratio that adheres to the ratio set forth by the Regional Center.

Plan submitted to Regional Center 01/22/2026.
Deficiency cleared.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Facility failed to ensure the 1 to 3 ratio multiple days in November 2025 and December 2025 which causes a potential risk to clients in care.
8
9
10
11
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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3