198602166-9-30-2021-28-AS-FFIS-C9225E-20211122160526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602166
Report Date: 09/30/2021
Date Signed: 09/30/2021 11:22:47 AM

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 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
06/08/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210608102553

FACILITY NAME:	SIESTA ASSISTED LIVING		FACILITY NUMBER:	198602166
ADMINISTRATOR:	MORENO, FRANCISCO		FACILITY TYPE:	740
ADDRESS:	163 N PASADENA AVENUE		TELEPHONE:	(626) 642-7409
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	6	CENSUS: 4	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Francisco Moreno; Administrator		TIME COMPLETED:	11:38 AM

ALLEGATION(S):

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Illegal eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted a subsequent complaint investigation regarding the allegation listed above. LPA met with Administrator Francisco Moreno and explained the reason for the visit.

The investigation consisted of the following: during the initial visit conducted on 06/06/21 by LPA Gonzalez, LPA obtained copies of Staff and Residents Rosters and Resident #1's (R1) Admission Agreement, Pre-Placement Appraisal, Reappraisal and a copy of Eviction Notice dated 6/5/21. During today's visit, LPA interviewed the Administrator and Staff #1.

The investigation revealed the following: in regards to the allegation "illegal eviction", it is alleged that R1 received an Eviction Notice which stated that she needed to be out of the facility by 07/04/21. No other details were provided. R1 moved into the facility on 03/18/21 and moved out on 07/10/21. LPA reviewed eviction notice dated 06/05/21 and observed that R1 was evicted because "resident has a need this facility can no longer care for within the limits of its state-issued license".

(CONTINUED ON 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210608102553

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SIESTA ASSISTED LIVING	FACILITY NUMBER: 198602166
	VISIT DATE: 09/30/2021

NARRATIVE

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The Department did not receive a written report of R1's eviction within 5 days of issue date as required under Title 22 Eviction Procedures 87224. Administrator indicated that this was the first time he had evicted a resident and believed he had to notify the Department of the eviction within 5 days of the resident moving out of the facility. Department first received notification of R1's eviction from the facility during the initial visit conducted on 06/16/21.

Based on LPA's observations and interviews which were conducted and record review, 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 8 are being cited on the attached LIC 9099D.

Exit interview held, and a copy of this report was provided along with appeal rights.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 28-AS-20210608102553

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SIESTA ASSISTED LIVING	FACILITY NUMBER: 198602166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/07/2021 Section Cited CCR 87224(f)	1 2 3 4 5 6 7	Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to read and review Eviction Procedures 87224. Administrator to submit self-certifying statement indicating he has read and understands the eviction procedures by POC due date.
	8 9 10 11 12 13 14	LPA did not receive noitifcation of R1's eviction within 5 days of issued date. This poses a potential Health,Safety, and/or Personal Rights risk to the residents 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.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

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