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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 05:03:10 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
11/29/2021 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211129162329
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:
03:00 PM
MET WITH:Rana ChapkenehTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff did not provide adequate supervison that resulted in client being hit by another client.
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 staff, attempted to interview residents #1-#3, and requested a copy of the staff and resident roster.

Regarding allegation: Staff did not provide adequate supervison that resulted in client being hit by another client. LPA interviewed R1, staff, and attempted to interview R1-R4. R2-R4 was not successful as they are non verbal and/or cannot communicate effectively to be understood. R1 was interviewed and indicated that R2 hits them, swings on them and has bullied them and staff does nothing about it. During the investigation it was communicated 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 3
Control Number 28-AS-20211129162329
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 R1's room and attacks them and also if they are in the common area R2 will hit and punch on them, staff and other residents in care. R1 said this has happened way too many times as they have lived in the facility for many years and nothing has been done about it. R1 said the other residents cant communicate so that's why R2 has gotten away with attacking them for many years. During the interview with staff it was communicated that R2 has lived there for many years and is not familiar with new people who may enter into the home which can cause them have behaviors, act out and throw tantrums. 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.

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: 3 of 3
Control Number 28-AS-20211129162329
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, punched or abused 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 3