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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601228
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:22:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
09/03/2024 and conducted by Evaluator Christian Gutierrez
COMPLAINT CONTROL NUMBER: 28-AS-20240903160504
FACILITY NAME:VERMONT CARE CENTERFACILITY NUMBER:
198601228
ADMINISTRATOR:ARLENE BARRIOSFACILITY TYPE:
735
ADDRESS:1316 S. VERMONT AVE.TELEPHONE:
(213) 384-1682
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:76CENSUS: 55DATE:
09/09/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Jeanine MachadoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst’s (LPA’s) Christian Gutierrez, Mayra Cota, and Licensing Program Manager (LPM) Tony Vasallo conducted an unannounced complaint investigation regarding the above allegations. LPA was met by Administrator Arlene Barrios and explained the purpose of the visit.

The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster (LIC 500), client roster (LIC 9020), C1’s identification and emergency information, house rules, physicians report dated 08/14/2024, SIR reports and eviction notice dated 8/26/2024, staff #1-2interviews (S1-S2), client #1 – 2 interviews (C1-C2).

The investigation revealed the following. Regarding allegation: Illegal Eviction-It is alleged C1 was illegally evicted from the facility. LPA reviewed the eviction noticed it was missing elements required per eviction procedures 80068.5 such as dates, places, and witnesses. SEE LIC 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
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-20240903160504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VERMONT CARE CENTER
FACILITY NUMBER: 198601228
VISIT DATE: 09/09/2024
NARRATIVE
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Interview conducted with clients confirmed C1 was served 30-day eviction that was missing elements per eviction procedures. Interviews with staff confirm C1 was provided 30 Day eviction notice for violent behavior. Staff confirmed C1 was provided a one-page eviction notice that was missing elements required.
Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Arlene Barrios. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240903160504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VERMONT CARE CENTER
FACILITY NUMBER: 198601228
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2024
Section Cited
CCR
80068.5(c)
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Eviction Procedures
The notice to quit shall state the reasons for the eviction, with specific facts supporting the reason for the eviction including the date, place, witnesses, if any, and circumstances.
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Administrator will revise 30 day eviction notice and will send revised notice to our department by 09/10/2024.
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This deficiency is evidenced by the following C1 was served 30 day eviction that was missing details such as dates, witnesses, and circumstances.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3