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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601896
Report Date: 12/16/2021
Date Signed: 12/20/2021 07:12:21 AM

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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2021 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211210115118
FACILITY NAME:JIDDE RESIDENTIAL HOME IIFACILITY NUMBER:
198601896
ADMINISTRATOR:DEXTER DIZONFACILITY TYPE:
735
ADDRESS:3702 STEARNLEE AVENUETELEPHONE:
(562) 377-0102
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:4CENSUS: 4DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Andrew NacionTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff transported client in vehicle without ensuring that client was wearing a seat belt.
INVESTIGATION FINDINGS:
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On 12/16/2021 at 9:45 a.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Andrew Nacion. LPA explained to Mr. Nacion the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (3) staff member and (4) clients on 12/16/21. In addition, on 12/16/21, LPA and Mr. Nacion conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. LPA also reviewed the following documents provided by Jidde Residential Home II, Administrator Mr. Nacion: LIC 500-staff roster, client roster, staff schedule, Incident Reports from November 2021 to present, Internal staff incident reports from November 2021 to present, House Rules, and C1’s IPP, C1’s physician report, and C1’s Needs Assessment plan.

Report continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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-20211210115118
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: JIDDE RESIDENTIAL HOME II
FACILITY NUMBER: 198601896
VISIT DATE: 12/16/2021
NARRATIVE
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Investigation

Allegation: Staff transported client in vehicle without ensuring that client was wearing a seat belt.

The investigation revealed, per LPA interviews, with (3) staff members, and (4) clients from the Jidde Residential Home II facility, and also review of facility documents, that the facility staff transported a client, in the facility vehicle, without wearing a seat belt. S1 informed the LPA that on 12/8/21, S1 drove C1, in the facility van, to C1’s doctor office, and later to the ER Hospital room, because C1 informed S1 that could not stand up and walk. S1 further stated, that when preparing C1 for medical transport, C1 could not lift self, in order to sit, in the van front or back van seat, and also C1 stated that C1 was afraid to stand up, because C1 believed might fall, trying to sit in the van seat, which C1 believed was high. S1 also stated, that because of C1's reluctance to sit in the van seat, S1 therefore, put the back seat down, and placed C1 on the van floor, while C1 was sitting on the van floor, C1 was holding onto the van’s back seat, not wearing a seat belt. Also, LPA interviewed 3 staff members and 3 of 3 staff members informed the LPA that on 12/8/21, C1 was transported by facility van to C1's doctor office, and ER hospital room, while sitting on the van’s floor and also without wearing a seat belt. In addition, LPA interviewed (4) clients, and 4 of 4 clients interviewed, informed the LPA, that the staff help them when needed, and that staff are available when needed.

On 12/16/21, at 10 am, S1 informed LPA Campos, that on 12/8/21, C1 was sitting on the facility van floor, and did not wear a seat belt, during transit to medical appointment and hospital.

Based on information gathered, LPA did find sufficient evidence to support allegation " Staff transported client in vehicle without ensuring that client was wearing a seat belt”

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Andrew Nacion and a hard copy of a LIC 9099 and LIC 9099D was provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20211210115118
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JIDDE RESIDENTIAL HOME II
FACILITY NUMBER: 198601896
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2021
Section Cited
HSC
80072(a)(2)
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80072(a)(2)Personal Rights(a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:..(2)To be accorded safe, healthful andcomfortable accommodations, furnishings and
equipment to meet his/her needs.
This requirement is not met as evidenced by:

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Administrator will fax to the LPA a copy of a facility client transportation procedures and also forward a copy of the training staff sign in of the client transporation procedures .

POC Due Date is 12/28/21
LPA Fax Number (323)981-1781
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Based on interviews, and record review, the licensee failed to ensure the safety of client C1, LPA was informed by S1, that on 11/9/21, C1 did not wear a facility van seatbelt, and also did not sit on a van seat, which posed a potential health risk to residents in care.

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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: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3