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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602272
Report Date: 12/06/2021
Date Signed: 12/06/2021 02:57:53 PM

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 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
11/29/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211129090333
FACILITY NAME:HOUSE OF HOPEFACILITY NUMBER:
198602272
ADMINISTRATOR:REYNAGA, VIVIANAFACILITY TYPE:
740
ADDRESS:14558 BROADWAY STREETTELEPHONE:
(562) 325-0572
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY:5CENSUS: 4DATE:
12/06/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Viviana Reynaga TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Licensee did not provide proper notification for fee increase
Licensee does not submit incident reports to Licensing as required
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Angelica Rea and Jewel Baptiste conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator/Licensee, Viviana Reynaga who assisted with today's visit.

Regarding the allegation that Licensee did not provide proper notification for fee increase. The investigation consisted of Interview with Licensee, and review of resident #1's file. Licensee stated that resident #1 required a higher level of care. Licensee stated that she provided resident #1's authorized representative with a notice of rate increase on 11/9/21. LPA Rea reviewed the document and observed that it did not include an itemization of the charges. Regarding the allegation that Licensee does not submit incident reports to Licensing as required, the investigation consisted of interview with Licensee and review of resident #1's file. Licensee admitted that there was an incident that occurred on 10/27/21. Licensee stated that the fire department was called for assistance with resident #1, however a special incident report was not submitted to Licensing.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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 4
Control Number 28-AS-20211129090333
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: HOUSE OF HOPE
FACILITY NUMBER: 198602272
VISIT DATE: 12/06/2021
NARRATIVE
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Based on interviews conducted and documents received, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of regulations Title 22, Divison 6 are being cited on the attached LIC 9099D

An exit interview was conducted with Administrator/Licensee, and a copy of report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/29/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211129090333

FACILITY NAME:HOUSE OF HOPEFACILITY NUMBER:
198602272
ADMINISTRATOR:REYNAGA, VIVIANAFACILITY TYPE:
740
ADDRESS:14558 BROADWAY STREETTELEPHONE:
(562) 325-0572
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY:5CENSUS: 4DATE:
12/06/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Viviana Reynaga TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Licensee did not communicate with authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Angelica Rea and Jewel Baptiste conducted an unannounced complaint visit in response to the above allegation. LPA met with Administrator, Viviana Reynaga who assisted with today's visit.

Regarding the allegation that Licensee did not communicate with authorized representative, the investigation consisted of interview with Administrator, and review of resident #1's file. Administrator denied that she did not communicate with resident #1's authorized representative. LPA observed detailed communication with licensee and resident #1's authorized representative.

Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20211129090333
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: HOUSE OF HOPE
FACILITY NUMBER: 198602272
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
HSC
1569.657(a)
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a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.
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Licensee shall ensure that the facility is in compliance with Title 22 regulations and Health and Safety code.
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This requirement is not being met as evidenced by:

LPA Rea observed that the increase notice provided to resident #1's authorized representative did not include an itemization of charges.
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Licensee shall review Health and Safety code 1569.657 and will send a written statement to LPA, stating that she has reviewed the section and will comply with it by 12/13/21.
Type B
12/13/2021
Section Cited
CCR
87211(a)(1)(D)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee shall ensure that the facility is in compliance with Title 22 regulations. Licensee will submit special incident reports as required.
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D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement wsa not being met as evidenced by: Licensee admitted that a Special incident report was not submitted to for incident which occurred on 10/27/21, in which fire department was called.
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Licensee will review Title 22 section 87211, and will send a written statement to LPA, stating that she has reviewed the section and will comply with it by 12/13/21.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4