198602190-3-10-2023-11-AS-MVAO-CQBTRW-20230327145811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602190
Report Date: 03/02/2023
Date Signed: 03/10/2023 10:29:39 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
02/28/2023 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230228155029

FACILITY NAME:	CASA DEL SOL RESIDENCE		FACILITY NUMBER:	198602190
ADMINISTRATOR:	JACOBS, DOV E		FACILITY TYPE:	740
ADDRESS:	11606 11602 W WASHINGTON BLVD		TELEPHONE:	(323) 678-4426
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90066
CAPACITY:	12	CENSUS: 8	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Valorie Hanson, Social Worker Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility ceiling is in disrepair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ana Soto conducted an initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Valorie Hanson, Social Worker Manager.

The investigation consisted of following: Interviews and Record reviews. On 03/02/2023, LPA Soto interviewed S#1 - Social Worker Manager, & S#2, R#1 - R#3. LPA toured office, dining area, patio between buildings, 3 buildings ( main building and 2 east side building housing (roomsJ, H, I, L, D, and G.) LPA took pictures of water damage and personal heater in room #J and sand bags pLaed in front of outside room D back door. On 03/02/23, LPA Soto received the following documents: Resident and Staff Roster, Repair invoice (estimate,) and Previous repair invoice for roof.

Based on the LPA's investigation, the investigation revealed the following. For Allegation – Facility ceiling is in disrepair. LPA toured 3 buildings and in room J there was water damage in room ceiling near both vents and bathroom ceiling.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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 11-AS-20230228155029

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: CASA DEL SOL RESIDENCE	FACILITY NUMBER: 198602190
	VISIT DATE: 03/02/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The outside hallway had water damage also. A pipe outside the main building was broken and water was entering room D back door. They placed sand bags to keep water from entering room and fixed pipe. The heater thermostat was replaced with a new one. LPA observed heat in the building housing rooms J, H, and I, where thermostat was replaced. Interviews with S#1 & S#2, communicated that they repaired the leaks in the room with a mixture as a temporary fix, until roofers can come to fix roof. The roofing company needed the rain to stop, in order to be able fix the roof, the roof needs to be completely dry. The facility installed a new thermostat for heat. The heater is now repaired and heat restored to the building. There was a broken pipe outside the main building and they fixed the pipe and placed sand bags in front of back door of room D to stop water from entering room. Interviews with R#1, communicated that the roof was leaking a lot of water, R#1 was utilizing towels to stop the water. R#1 also had no heat in their room and used a personal heater. R#2 & R#3, communicated they had no water leaks and their rooms where at a comfortable temperature. No heat issues. The facility had the roof repaired on 01/28/23, but the roof is still not repaired. The roofing company will be repairing the roof again, the roof repaired are still within warranty period. The interviews, record reviews, and observations, concur with the above allegation,

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Valorie Hanson, Social Worker Manager, and a hard copy of report and Appeal Rights provided

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230228155029

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: CASA DEL SOL RESIDENCE	FACILITY NUMBER: 198602190
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/08/2023 Section Cited CCR 87303a	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by:	1 2 3 4 5 6 7	Administrator to repair roof asap. Send copy of completed repairs invocie by or on POC due date.
	8 9 10 11 12 13 14	based on room J water leak and no heat and pipe broken outside room G main building.	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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3