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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601668
Report Date: 08/25/2023
Date Signed: 08/25/2023 03:21:07 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
07/25/2023 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230725104700
FACILITY NAME:CASA MENENDEZFACILITY NUMBER:
198601668
ADMINISTRATOR:RAFAEL MENENDEZFACILITY TYPE:
735
ADDRESS:8521 STEWART & GRAY RD.TELEPHONE:
(562) 381-0000
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:4CENSUS: 4DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Samira Menendez- Co-AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure facility was free from bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to investigate the above allegation. LPA met with Samira Menendez, Co-Administrator and discussed the purpose of today's visit.

During the initial visit conducted on 8/01/2023, LPA Pena obtained copies of Staff and Client Rosters, Staff Shift Duties and staff & clients contact information. LPA conducted a tour of the facility focusing on the clients’ mattresses in the bedrooms and living room furniture such as sofas, decorative pillows. LPA inspected all four (4) client’s beds/mattresses, head boards, bed frames to check bed bugs and took photos. LPA also interviewed Staff #1 (S1).

During today’s visit, LPA Pena obtained copies of Staff and Client Rosters, interviewed Staff #2 (S2) – Staff #5 (S5), attempted to interview Client #1 (C1) – Client #3 (C3) but they are all non verbal. LPA attempted to talk to Client #4 (C4) on the phone and called him 3x (@1:56pm, 2:30pm and 4:24pm), but C4 did not answer nor return the call. ****CONTINUED ON LIC9099-C****
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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 3
Control Number 28-AS-20230725104700
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: CASA MENENDEZ
FACILITY NUMBER: 198601668
VISIT DATE: 08/25/2023
NARRATIVE
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The investigation revealed the following: In regards to the allegation, “Staff did not ensure facility was free from bed bugs”, it is alleged that the facility has bed bugs and the staff knows but is not taking the steps to ensure facility is free from bed bugs. Additionally, it is alleged that staff and residents are getting bit by bed bugs. 6 of 6 staff interviewed denied the allegation. All 6 staff members stated that they did not see bed bugs in the facility. S1-S2 stated that they are not aware of the bed bugs and no one has brought this to their attention. 3 of 4 clients are nonverbal and could not confirm or deny the allegation. LPA attempted to speak with Client #4 (C4) on the phone, but no answer and C4 did not return the call. File review does not show the facility has been treated for bed bugs. S1 stated that the facility does not have an ongoing or scheduled pest/bug control service. During the initial visit on 8/01/2023, LPA observed bed bugs in C1 & C2’s mattresses (bedroom #1) & C4’s mattress (bedroom #2). LPA took photos and showed it to S1. Therefore there was sufficient evidence to corroborate with this allegation.

Based on LPA’s observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency cited on the attached LIC 9099-D. An exit interview was conducted, and a copy of this report was provided to Christina Jimenez, Direct Support Professional I & II along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230725104700
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: CASA MENENDEZ
FACILITY NUMBER: 198601668
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2023
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary ....at all times for the safety and well-being of clients, employees....(1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
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Administrator agreed to dispose all the clients mattresses and purchase new ones. Additionally, Administrator will maintain a contract with pest control company to address the bed bug problem, until the facility is free of bed bugs. CONT....
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LPA observed bed bugs in C1-C2's mattresses in bedroom #1 and C3's mattress in bedroom #2 on 8/01/2023 during the facility inspection. LPA took photos and showed it to S1.
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Administrator will comply with all recommendations given by pest control company. Administrator will send photos of the new mattresses, receipts and service report from the pest control company to LPA by POC due date.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3