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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600856
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:57:41 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
09/20/2022 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220920104259
FACILITY NAME:LARDIZABAL HOMEFACILITY NUMBER:
198600856
ADMINISTRATOR:MARY ANNE NACUAFACILITY TYPE:
735
ADDRESS:212 LONE HILL AVETELEPHONE:
(626) 857-1071
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 4DATE:
03/11/2024
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Mary Anne Nacua, AdministratorTIME COMPLETED:
04:03 PM
ALLEGATION(S):
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Facility falsified information reported to the department.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPA) made unannounced visit to investigate the above allegation. LPA was greeted by Senoron Lucia DSP who allowed entry. LPA explained the purpose of the visit. Administrator Mary Anne Nucua arrived a short time later and assisted with the visit.

The investigation consisted of interviews with 4 Staff (S#1- S#4) and two witnesses W#1-W#2. LPA also reviewed incident report dated 09/04/2022 (CAP) sent by W#2 and 812 documenting interaction between Administrator and LPA Maldonado.

The investigation revealed that when C1 was in distressed, both staff admitted to being in state of shock and could not recollect the details of the incident that occurred on 09/03/2022. There was two discrepancies that were reported to Regional Center as well as the department. 1) Administrator reported that she was present during the incident. In reality, Administrator was actually driving towards the facility when she received the call from caregivers regarding C1 being in distress. (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: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
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 3
Control Number 28-AS-20220920104259
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: LARDIZABAL HOME
FACILITY NUMBER: 198600856
VISIT DATE: 03/11/2024
NARRATIVE
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2) The administrator reported to Regional Center that C1 was in the dining room when in distress. S4 stated that C1 was in dinning room when C1 began to have difficulty breathing. However, S3 stated C1 was in C1 bedroom. For the second inaccuracy, there is conflicting details. S1 stated she made a mistake by stating she was at facility when C1 started to be in distress and having trouble breathing. W2 Regional Center QA, stated that facility reported to them that Administrator was at facility and that C1 was in the dining room which was not accurate. W2 didn't not believe there was any ill intent on part of facility when reporting the incident details inaccurately. It was established by LPA that C1 was in C1 room during the incident.


Based on LPA’s interviews which 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, Chapter 1 is being cited on the attached LIC 9099D.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220920104259
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: LARDIZABAL HOME
FACILITY NUMBER: 198600856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2024
Section Cited
CCR
80012(a)
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False claims. No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement was not met as evidenced by:
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The Licensee shall read Section 80012 and provide to LPM Lopez a written statement that she will not make false statements to CCL Staff. The written statement shall be provided to CCL to the attention of LPM Lopez by the POC Date.
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Administrator and staff made false statements regarding details of the incident on 09/03/2022. Administrator reported she was present during the incident, when Administrator was actually driving to facility, and Administrator reported incident occurred in dining area to Regional Center when it actually happened in C1 room.
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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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3