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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601604
Report Date: 12/29/2022
Date Signed: 12/29/2022 10:01:39 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2022 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220601084046
FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:4CENSUS: 4DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Rosanna CarranzaTIME COMPLETED:
10:22 AM
ALLEGATION(S):
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Resident was left in soiled clothing for a period of time.
INVESTIGATION FINDINGS:
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On 12/29/2022, Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint investigation for the allegation listed above to deliver findings. Today’s complaint investigation was conducted with Rosanna Carranza.

The investigation consisted of the following: On 06/09/2022 Licensing Program Analyst (LPA) Don interviewed clients (C1-C3, staff (S1-S5) and W1). LPA requested and obtained pertinent documents.
During the course of the investigation, LPA was able to find evidence supporting the allegation. Record reviews indicate that C1 and C2 need full assistance with incontinence care. Record reviews indicate that C1 and C2 were left in soiled clothing on 05/17/2022. Interviews indicate the following: staffs S1 through S5 verified that C1 and C2 needs assistance with their toileting needs. S1 verified that S6 was working from 10pm to 6am between 05/16/2022 and 05/17/2022. S2 verified that C1 and C2 were left in soiled clothing during S6 shift. Witness (W1) verified that the incident about C1 and C2 being left in soiled clothing during S6 shift was substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 11-AS-20220601084046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2023
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care and Supervision. In addition to Section 80078, the following shall apply: The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. Based on record reviews and interviews,
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The licensee agreed to read, understand, sign and date Title 22 Regulations on Responsibility for Providing Care and Supervision 85078(a)(1). Licensee to do in-service training with staff on soiled clothing and toileting and send proof of the in-service, with signatures, of staff.
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the licensee failed to ensure that services identified in the client's needs and services plan as necessary to meet the client's needs were provided, clients (C1-C2) were left in soiled clothing for a period of time which poses a potential health and safety risk to persons in care.
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Proof of correction to CCLD by POC due date of 01/12/2023.

A copy of this report and appeals rights were provided during the visit.
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20220601084046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 12/29/2022
NARRATIVE
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Based on LPA’s interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Resident was left in soiled clothing for a period of time” through neglect and lack of care and supervision is found to be “Substantiated” California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3