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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602255
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:10:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
01/18/2024 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20240118094819
FACILITY NAME:CALIFORNIA MENTOR - DOMINGUEZ HOMEFACILITY NUMBER:
198602255
ADMINISTRATOR:ROSAS, CLAUDIOFACILITY TYPE:
735
ADDRESS:214 E DOMINGUEZTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:3CENSUS: 3DATE:
01/25/2024
ANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Ife James, Area DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility failed to meet the reporting requirements.
INVESTIGATION FINDINGS:
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On 01/25/2024 at around 8:14 AM Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Socorro Leandro initiated a complaint investigation regarding the allegation listed above. LPM and LPA meet with Direct Support Professional (DSP) Astly Sale and the purpose of this visit was explained. The team was later joined by Program Director Nickie Southall and Area Director Ife James.

The investigation consisted of the following: On 01/18/2024 and 01/25/2024 El Segundo Community Care Licensing (CCL) team reviewed Departmental Records for this facility. During today’s investigation LPM, LPA, and DSP conducted a tour of the facility. LPM and LPA interviewed 2 out 3 clients (1 out 3 clients were not available due to their medical condition) and 6 staff. LPM and LPA reviewed client records, UIR/SIRs, hospital records, regional center special incident reports (SIR), and facility records. At around 11:00AM LPM and LPA exited the facility and at around 1:00PM LPM and LPA resumed the investigation.

Please see LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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-20240118094819
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255
VISIT DATE: 01/25/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation "Facility failed to meet the reporting requirements” it is being alleged that the facility failed to submit incident reports to the Licensing Department. Staff Interviews and Records reviews indicate the following: hospital and facility records indicate that C1 was taken to the hospital on 12/15/2023 after a fall incident and was also taken to the hospital on 01/15/2024 for a scheduled surgery. Staff S1 and S4 verified that both incidents occurred. Record reviews of facility records did not indicate evidence of when and how the incidents were submitted to the Licensing Department. Record reviews of the Departments records conducted on 01/18/2024 and 01/25/2024 did not indicate receipt of reports regarding the said incidents. Regarding the allegation “Facility failed to meet the reporting requirements,” the preponderance of the evidence standard has been met therefore the allegation is substantiated.

An exit interview was conducted and plans of correction were developed. A copy of this report was provided to Area Director.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20240118094819
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2024
Section Cited
CCR
80061(b)(1)(D-E)
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Reporting Requirements Upon the occurrence, ...,of any of the events specified...a report shall be made to the licensing agenc...within seven days ... event. Events... injury ...treatment. Any unusual... absence ...(a). This requierment was not meet by evidence by:
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Licensee will create a plan to ensure future compliance with CCR Title 22 regulation 80061(b)(1)(D-E) Reporting Requierments and submit proof of correction to Socorro.Leandro@dss.ca.gov.
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Based on interviews and record the license did not ensure that reports were made to licensing agency within seven days of C1's hospitalizations of 12/15/2023 and 01/15/2024 which poses a potential health and safety risks to clients 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3