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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601402
Report Date: 04/20/2022
Date Signed: 04/20/2022 05:00:17 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
04/11/2022 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220411121338
FACILITY NAME:DE LEON HOMEFACILITY NUMBER:
198601402
ADMINISTRATOR:MAUREEN DELEONFACILITY TYPE:
735
ADDRESS:11503 FERINA STTELEPHONE:
(562) 900-2717
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:4CENSUS: 4DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Monica Chavez
Flores		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Client hits another client while in care.
Client is not being properly fed while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted an initial 10 day complaint investigation for the allegation listed above. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. LPA met with staff Evelyn Lizarraga and Monica Chavez Flores. LPA spoke to Administrator Rana Chapkhaneh on the phone who allowed the staff to sign the reports on her behalf.

The investigation consisted of the following: LPA Wesley interviewed the Administrator, staff, Residents, other parties, and requested a copy of the staff roster, resident roster, facility menu, ID page(facesheet), current physician report, current IPP.

Regarding allegation: Client hits another client while in care. LPA interviewed R1, staff, other parties and attempted to interview R2-R4 and was not successful as they are non verbal and/or cannot communicate effectively to be understood. The investigation revealed that R2 hits them, swings on them and has bullied them and staff does nothing about it. During the investigation it was revealed that the staff allows R2 to enter
Continued on LIC 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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 5
Control Number 28-AS-20220411121338
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: DE LEON HOME
FACILITY NUMBER: 198601402
VISIT DATE: 04/20/2022
NARRATIVE
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into other clients personal space and hits/punches them without being redirected and the explanation the clients receive is that R2 has lived there for many years and is not familiar with new people who enters into the home. Interviews with other parties also revealed that on several occasions R2 has hit them, as well as other staff and clients living in the home and nothing has been done about it. R3-R4 are non verbal and cant express themselves, which makes it hard for them to communicate to staff. During the interview with the Administrator, she advised that she was aware that R2 hit the clients and redirects and tries to keep them separate so R2 can keep their hands to themselves. During the interviews with staff it was also confirmed that R2 has behaviors and will act out and throw tantrums.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights given.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20220411121338
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: DE LEON HOME
FACILITY NUMBER: 198601402
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
80072(a)(2)
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Personal Rights
Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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The facility Administrator shall have an in service training with all staff on Personal Rights. The facility Administrator will develop a plan that will allow clients to feel safe when they enter into the common areas of the home without having fear of being hit or punch by R2.
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This requirement has not been met as evidence by: The facility staff allows R2 to hit and punch on other clients in the home which poses a health and safety concern to clients in care
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Please provide the proof of corrections: in service sign and the plan by 05/05/2022.
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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: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/11/2022 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220411121338

FACILITY NAME:DE LEON HOMEFACILITY NUMBER:
198601402
ADMINISTRATOR:MAUREEN DELEONFACILITY TYPE:
735
ADDRESS:11503 FERINA STTELEPHONE:
(562) 900-2717
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:4CENSUS: 4DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rana ChapkhanehTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Client is not being properly fed while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted an initial 10 day complaint investigation for the allegation listed above. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. LPA met with Administrator Rana Chapkhaneh.

The investigation consisted of the following: LPA Wesley interviewed the Administrator, staff, Residents, other parties, and requested a copy of the staff roster, resident roster, facility menu, ID page(facesheet), current physician report, current IPP.

Regarding allegation: Client is not being properly fed while in care. The Administrator was interviewed and advised that R1 doesn't like the type of food being served in the facility and advised that they would try to accommodate some food options for R1. LPA was also informed that R1 purchased a small refrigerator and so they could have some food items and beverages of their choice and prevent others from touching their food.
Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220411121338
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: DE LEON HOME
FACILITY NUMBER: 198601402
VISIT DATE: 04/20/2022
NARRATIVE
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During the interview with R1 they advised they dont make food she likes, and she also asked if they could purchase some granola and they haven't. R1 also said that the facility doesn't have a meal plan and she spoke to the Administrator and they agreed to provide some of the meals that they like on Monday, Wednesday, Friday, and Saturday. R1 advised the other day, the facility staff did prepare a meal that she liked, the interview also revealed that the resident does not like vegetables and pork. The facility has to provide a balanced meal according to the title 22 regulations and can not provide meals that are not healthy several times a week. LPA Wesley attempted to interview R2-R4 and was not successful as they are non verbal and/or cannot communicate effectively to be understood.


Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore the allegation is UNSUBSTANTIATED.

There are no deficiencies cited

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5