198602183-7-30-2021-28-AS-MVAO-C75PN6-20210923112727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602183
Report Date: 07/30/2021
Date Signed: 07/30/2021 02:24:31 PM

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
06/03/2020 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200603150845

FACILITY NAME:	JORDAN GUEST HOME		FACILITY NUMBER:	198602183
ADMINISTRATOR:	BOHANAN, VILMA TRAZO		FACILITY TYPE:	740
ADDRESS:	10657 JORDAN ROAD		TELEPHONE:	(562) 822-4677
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	6	CENSUS: 6	DATE:	07/30/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Vilma Bohanon		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not keep the facility free from rodents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation for the allegation listed above. Today's complaint investigation was conducted with Administrators Vilma Bohanan and James Trazo.

During the initial visit investigation on 6/8/2020, LPA called and interviewed Staff #1-#2 (S1-S2) and residents #1-#6 (R1-R6). LPA also requested documentation from exterminator company showing dates of service and reasons for the services.

On Todays visit LPA toured the physical plant and delivered findings. Regarding the above allegation of "staff did not keep the facility free from rodents", it was alleged that a mouse was observed in the facilities kitchen multiple times in the month of May 2020....

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

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-20200603150845

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: JORDAN GUEST HOME	FACILITY NUMBER: 198602183
	VISIT DATE: 07/30/2021

NARRATIVE

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(2) of (2) staff interviewed corroborated the allegation. (1) of (6) residents interviewed stated that they have seen rodents in the facility or were aware of rodents in the facility. (5) of (6) residents could not corroborate the allegation. Interviews with staff and resident show that rodents were seen by the kitchen counter tops and floors of the kitchen. Review of documents obtained show that the facility scheduled an extermination company to address the rodent issue in the facility on 6/8/2020. The investigation revealed that the staff failed to keep the facility free of rodents as shown by interviews conducted and documents collected.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted with Administrators Vilma Bohanon and James Trazo. Appeal rights were explained. Copy of the investigation report was provided along with the appeal rights.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200603150845

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: JORDAN GUEST HOME	FACILITY NUMBER: 198602183
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/30/2021 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements. (b)The following food service requirements shall apply:(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.	1 2 3 4 5 6 7	Facility had addressed the situation before time of this visit. Exterminator documents collected show they arrived on 6/8/2020 to do treatment at the facility. LPA observed the facility to be clean and in good repair. Proof of correction has been completed.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Staff and residents stating they have seen rodents in the kitchen and documentation for rodent extermination. This poses a potential health and safety risk to residents in care and supervision.	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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC9099 (FAS) - (06/04)

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