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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601896
Report Date: 09/22/2022
Date Signed: 09/22/2022 04:56:56 PM

Unsubstantiated


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
09/12/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220912173308
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:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Andrew Nacion, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff slapped resident.
INVESTIGATION FINDINGS:
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On 9/22/2022, Licensing Program Analyst (LPA) Martessa Brown conducted a 10-day complaint visit at this facility regarding the allegation mentioned above. LPA Brown conducted risk assessment before entering the building. LPA was met by caregiver Estrella Peones and Administrator Andrew Nacion explained the purpose of today’s visit.

The investigation consisted of the following: LPA conducted interviews with the Administrator, staff #1 and clients #3-#4. LPA reviewed and obtained client and staff roster, C1’s admission agreements, physicians reports, behavior reports, emergency contact, incident report and IPP. LPA toured the facility with the administrator. No clients were present and at the Adult Day program.

The investigation revealed the following:
LIC 9099-C is on the next page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 2
Control Number 11-AS-20220912173308
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: JIDDE RESIDENTIAL HOME II
FACILITY NUMBER: 198601896
VISIT DATE: 09/22/2022
NARRATIVE
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Regarding the allegation: Staff slapped resident.

On 9/22/2022, details of the allegation stated client was slapped by administrator on the way to the doctor’s office. LPA brown conducted interview with the administrator, he stated took C1 to the doctors at 3:40 pm and stayed at the office. Administrator stated there was no type physical abuse. He stated the client was fine. He stated the day program had informed him what the client had said. He also stated police came to the day program, but no report was made, and client did not want to speak with them. LPA interviewed Staff #1 stated heard about the incident but is not true. Staff also stated has not witness any physical abuse or clients had no concerns. LPA called the day program and attempted to interview C1 from but did not want talk. C2 was not available to interview. LPA interviewed over the phone clients C3-C4 and they stated they have not been physically abused by administrator or staff at the facility or while traveling. Clients stated staff treat them fine. treats them fine. LPA review client incident report and C1’s IPP mentioned client likes to fabricate stories.

Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.



An Exit interview was conducted and report given to Andrew Nacion.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2