198601402-5-1-2023-28-AS-TVAO-CSDS6F-20230601133548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601402
Report Date: 05/01/2023
Date Signed: 05/01/2023 08:12:36 PM

Unsubstantiated

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
03/16/2022 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220316152318

FACILITY NAME:	DE LEON HOME		FACILITY NUMBER:	198601402
ADMINISTRATOR:	MAUREEN DELEON		FACILITY TYPE:	735
ADDRESS:	11503 FERINA ST		TELEPHONE:	(562) 900-2717
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	4	CENSUS: 4	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Administrator Rana Chapkhaneh		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident is being denied food while in care.
Resident's requests for communication with staff are not responded to in a timely manner.
Resident is being yelled at while in care.
Resident is being spoken to in an inappropriate manner while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint visit on 05/01/23, stemming from initial 10-day complaint visit dated 03/22/22, conducted by LPA Wesley. LPA Ramirez gained entry into the facility and was met by Relief Administrator Rana Chapkhaneh. LPA explained the purpose of the visit and toured the facility. Administrator Peggie De Leon arrived shortly after.

The investigation consisted of the following: LPA Ramirez interviewed staff, attempted to interview Client #1 – 4 (C1- C5), requested and obtained copy of the staff, resident roster C1’s face sheet and other pertinent documents related to this investigation.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220316152318

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: DE LEON HOME	FACILITY NUMBER: 198601402
	VISIT DATE: 05/01/2023

NARRATIVE

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Allegations:

· Resident is being denied food while in care. It is alleged C1 was being denied food by staff and staff was instructed to not prepare meals for C1. Three out of the three staff interviewed deny this allegation. According to staff, C1 had purchased their own mini refrigerator and kept some food items in that refrigerator. Staff deny receiving instruction to not prepare meals for C1 by Administrator or Licensee. Based on records review, LPA Ramirez discovered C1 has a history of making false allegations that someone is taking/eating her food and that C1 has food available but chooses not to look for items and make false allegations against staff. C1 was no longer a resident at the facility. LPA Ramirez attempted to interview C1 via phone but, C1 was not available at this time. C2 – C5 were not able to be interviewed due to cognitive abilities.

· Resident's requests for communication with staff are not responded to in a timely manner. It is alleged C1 has made multiple attempts to speak with Administrator Chapkhaneh and staff or Administrator Chapkhaneh respond. Three out of the three staff interviewed deny this allegation. LPA Ramirez attempted to interview C1 via phone but, C1 was not available at this time. C2 – C5 were not able to be interviewed due to cognitive abilities. According to Administrator Chapkhaneh, C1 would come and speak to her but C1 would become easily agitated and begin yelling. Based on records review, LPA Ramirez discovered staff notes dated 02-01-22 through 05-23-23, that documents Administrator Chapkhaneh and other staff communicating with C1 and staff documenting C1’s responses.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220316152318

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: DE LEON HOME	FACILITY NUMBER: 198601402
	VISIT DATE: 05/01/2023

NARRATIVE

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· Resident is being yelled at while in care. It is alleged C1 was yelled ay by staff. Three out of the three staff interviewed deny this allegation. LPA Ramirez attempted to interview C1 via phone but, C1 was not available at this time. C2 – C5 were not able to be interviewed due to cognitive abilities. During tour of facility, LPA Ramirez observed several staff attending to clients in care and did not observe and hazards, or health and safety violations. Bases on records review, LPA Ramirez discovered several documented notes of staff indicating C1 began to yell and become upset, due to staff asking C1 to perform a house rule task; staff had to intervene and redirect C1.

· Resident is being spoken to in an inappropriate manner while in care. It is alleged C1 was spoken to inappropriately by staff on several occasions. Three out of the three staff interviewed deny this allegation. LPA Ramirez attempted to interview C1 via phone but, C1 was not available at this time. C2 – C5 were not able to be interviewed due to cognitive abilities. During tour of facility, LPA Ramirez observed several staff attending to clients in care and did not observe and hazards, or health and safety violations.

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.

Exit interview held, and a copy of this report was provided via email due to printer problem.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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