198601526-6-2-2023-28-AS-DSIS-CV2TUR-20230825150245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601526
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:26:30 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
06/01/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230601104032

FACILITY NAME:	JULSTIN RESIDENTIAL CARE CENTER		FACILITY NUMBER:	198601526
ADMINISTRATOR:	OMAR SAPALARAN		FACILITY TYPE:	735
ADDRESS:	2318 E. WALNUT CREEK PKWY		TELEPHONE:	(626) 862-7207
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	4	CENSUS: 4	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Omar Sapalaran		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff serve expired foods.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Licensee Josephine Sapalaran who allowed entry into the facility and was later met by Administrator Omar Sapalaran who assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed the administartor in the facility, four staff (S1-S4) via telephone, three clients (S1-S3) at the day program and attempted to interview one client (C4) on the phone and inspect the perishable food in the refrigerator and garage and non perishable food in the ktichen cabinet and the garage.

The investigation revealed of the following: "Facility staff served expired foods" LPA interviewed clients and they like the food in the facility but not sure if the food was expired or not.
(See LIC 9099C for continuation)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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-20230601104032

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: JULSTIN RESIDENTIAL CARE CENTER	FACILITY NUMBER: 198601526
	VISIT DATE: 06/02/2023

NARRATIVE

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LPA interviewed staff and all denied the allegation and stated they would toss the canned goods if they saw the canned good was expired and they would never sever it to clients. LPA inspected the canned goods from the facility kitchen cabinet and observed canned goods of chunk chicken breast, green beans, corned beef and peanut butter were expired. LPA also inspected the garage and observed some canned goods and the salad dressing were expired too.

Based on the LPA's observation, interviews conducted with staff and clients,, the preponderance of evidence standard has been met, therefore the above allegation(s) are 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 and copy of the report and appeal right were provided to the administrator Omar Sapalaran

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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
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
06/01/2023 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20230601104032

FACILITY NAME:	JULSTIN RESIDENTIAL CARE CENTER		FACILITY NUMBER:	198601526
ADMINISTRATOR:	OMAR SAPALARAN		FACILITY TYPE:	735
ADDRESS:	2318 E. WALNUT CREEK PKWY		TELEPHONE:	(626) 862-7207
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	4	CENSUS: 4	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Omar Sapalaran		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility is operating out of ratio.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted an Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Licensee Josephine Sapalaran who allowed entry into the facility and was later met by Administrator Omar Sapalaran who assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed the administartor in the facility, four staff (S1-S4) via telephone, three clients (S1-S3) at the day program and attempted to interview one client (C4) on the phone and inspect the perishable food in the kitchen and garage and non perishable food in the ktichen cabinet and the garage.

The investigation revealed of the following: Allegation "Facility is operating out of ratio." LPA interviewed clients and reported there's always staff in the facility and not known if the facility is operating out of ratio or not. (See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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-20230601104032

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: JULSTIN RESIDENTIAL CARE CENTER	FACILITY NUMBER: 198601526
	VISIT DATE: 06/02/2023

NARRATIVE

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LPA interviewed four staff and three out of four staff denied the allegation and reported the facility is not short staffing. LPA interviewed administrator and stated the facility is a Level 4C and no client required one on one and they are following the protocol/requirement which regional center required or provided. They never had any staffing issues. The facility always has two staff during the busy hours such as in the early morning 6-8am and afternoon from 4-7pm. LPA also observed the staff time sheets in the past two weeks and staff scheduled for this week.

Based on the interviews conducted with clients and staff, record reviewed and observation, the investigation revealed: Although the allegation 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 allegation is UNSUBSTANTIATED.

Exit interview conducted, and a copy of report and appeal right was provided to Administrator Omar Sapalaran.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230601104032

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: JULSTIN RESIDENTIAL CARE CENTER	FACILITY NUMBER: 198601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2023 Section Cited CCR 80076(a)(1)	1 2 3 4 5 6 7	80076 Food Services (a)In facilities providing meals to clients, the following shall apply:e age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. The requirement was not met as evidenced by:	1 2 3 4 5 6 7	.The administrator will review all the canned good in the facility and tossed all the one that expired and provide training to all staff for the regulation and send the staff training log to LPA by POC due date.
	8 9 10 11 12 13 14	LPA's observation, LPA inspected the facility kitchen cabinets and garage and observed canned good were expired which posed a potential risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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