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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600581
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:52:48 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
12/11/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241211095925
FACILITY NAME:HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOMEFACILITY NUMBER:
198600581
ADMINISTRATOR:VIDA ANDRADEFACILITY TYPE:
735
ADDRESS:11401 BLOOMFIELD, BLDG.305-307TELEPHONE:
(562) 207-9660
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:38CENSUS: 30DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Vida Andrade, AdministratorTIME COMPLETED:
03:57 PM
ALLEGATION(S):
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Due to lack of staff, bathrooms are not getting cleaned properly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegation. LPA was greeted by Service Coordinator Jasmine Moore and LPA discussed the purpose of the visit. Administrator Vida Andrade met with LPA a few minutes later and assisted with the visit.

The investigation consisted of LPA interviewing six (6) staff (S#1-S#6) and five (5) clients (C#1-C#5), reviewing and obtaining copies of Staff and Client rosters, C1 Medication Administration records (MAR) for November 2024 and December 2024, The six (6) Rights of Medication assistance. Resident Sign-out / Sign In Sheet for C1 dated from 02/07/2024-10/28/2024. Facility Protocol on Medication Refusal and Missed Medications, C1 face sheet, Physicians Report for Community Care Facilities (LIC602) for C1, C1 Face Sheet, Doctors Orders for C1 medications dated 09/24/2024 and LPA took tour of facility, including all 10 bathrooms and 10 random rooms with Manager Nicolas Novella and Administrator.

(Continued 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: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 6
Control Number 28-AS-20241211095925
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: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME
FACILITY NUMBER: 198600581
VISIT DATE: 12/17/2024
NARRATIVE
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(Continued from 9099)
Allegation: Due to lack of staff, bathrooms are not getting cleaned properly. It is alleged that due to being short staff the facility rooms and bathrooms are not being cleaned.

The investigation revealed:

LPA interviewed six (6) staff and four (4) of six (6) staff denied the allegation. LPA interviewed five (5) clients and four (4) of five (5) clients stated that the restrooms are uncleaned at some point in the day. Administrator stated that clients are encouraged to keeping their restrooms and rooms clean and that most clients keep the cognizant of that. LPA toured 10 bathrooms and 10 random rooms and observed one bathroom uncleaned with grime around the tub, sink and walls. S1 stated that one housekeeper recently passed away. There is enough evidence to support this allegation.

Based on interviews conducted and LPA observations, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. The deficiencies are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights were provided.

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

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20241211095925
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: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME
FACILITY NUMBER: 198600581
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) 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 met as evidenced by:
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Housekeeper cleaned the bathroom during the visit. ****NO FURTHER ACTION REQUIRED***
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LPA observed one (1) of ten (10) bathrooms in facility to be unclean. The tub, sick and wall was uncleaned.
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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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
12/11/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241211095925

FACILITY NAME:HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOMEFACILITY NUMBER:
198600581
ADMINISTRATOR:VIDA ANDRADEFACILITY TYPE:
735
ADDRESS:11401 BLOOMFIELD, BLDG.305-307TELEPHONE:
(562) 207-9660
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:38CENSUS: 30DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Vida Andrade, AdministratorTIME COMPLETED:
03:57 PM
ALLEGATION(S):
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Staff are not giving resident medication.
Staff do not answer phones when residents call.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations. LPA was greeted by Service Coordinator Jasmine Moore and LPA discussed the purpose of the visit. Administrator Vida Andrade met with LPA a few minutes later and assisted with the visit.

The investigation consisted of LPA interviewing six (6) staff (S#1-S#6) and five (5) clients (C#1-C#5), reviewing and obtaining copies of Staff and Client rosters, C1 MAR for November 2024 and December 2024, The six (6) Rights of Medication assistance. Resident Sign-out / Sign In Sheet for C1 dated from 02/07/2024-10/28/2024. Facility Protocol on Medication Refusal and Missed Medications, C1 face sheet, Physicians Report for Community Care Facilities (LIC602) for C1, C1 Face Sheet, Doctors Orders for C1 medications dated 09/24/2024 and LPA took tour of facility, including all 10 bathrooms and 10 random rooms with Manager Nicolas Novella and Administrator.

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

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 6
Control Number 28-AS-20241211095925
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: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME
FACILITY NUMBER: 198600581
VISIT DATE: 12/17/2024
NARRATIVE
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(Continued from 9099)

Allegation: Staff are not giving resident medication. It is alleged that client was out late with family one night and arrived at facility around 10:00PM and staff refused to dispense his medications that night.

The investigation revealed:

LPA interviewed six (6) staff and four (4) of (6) staff acknowledged that facility did not provide C1 with C1 medications on 12/13/2024 due to arriving to facility outside the window his doctor ordered.

S5 stated that on 12/13/2024 C1 arrived at facility around 10:00PM after being out with friends. S5 stated that the facility has a One (1) hour window on each side of hour C1 doctor has ordered to dispense C1 medication and C1 time is 5:00PM each evening. S1 stated it would be medication error if they were to dispense C1 medication that late.

LPA reviewed Medication record for C1 for month of November 2024 and December 2024.

LPA reviewed documentation on back of Medication Record and it showed that on 11/17/2024, C1 refused all bedtime medications. On 11/28/2024, C1 was out that evening during the window to dispense C1 medication and did not get C1 dosage. On 12/09/2024, C1 refused all C1 bedtime medication. On 12/13/2024, C1 was out of the facility during the time medication is dispensed and missed C1 dosage on this day.

LPA interviewed five (5) clients and four (4) of (5) clients stated they get their medications daily and on time. S1 and S5 stated they encouraged clients to take their medication and that it is encouraged but staff will not dispense medication out of the window that client’s doctor has ordered. It is deemed to be too dangerous and against facility policy to go against doctor’s orders. There is not enough evidence to support the allegation that facility staff is not giving resident his medication at the hour it is required to be given.

Allegation: Staff do not answer phones when residents call. It is alleged that staff do not answer the phones or hang up on clients who call.

The investigation revealed:

LPA interviewed six (6) staff and all six (6) of six (6) staff all denied the allegation. LPA interviewed five (5) clients and four (4) of five (5) clients were not able to corroborate the allegation. Phone was answered by staff during the visit today. There is not enough evidence to support the allegation.

Based on observations, file review and interviews; although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED

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

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6