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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602375
Report Date: 09/09/2021
Date Signed: 09/10/2021 09:26:15 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
09/01/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210901145313

FACILITY NAME:ROSTAR HOME II INCFACILITY NUMBER:
198602375
ADMINISTRATOR:THENG, THANAFACILITY TYPE:
735
ADDRESS:1527 WEST 247TH PLACETELEPHONE:
(310) 326-1746
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:4CENSUS: 4DATE:
09/09/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Thana Theng, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility walls in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto initiated a complaint investigation for the allegations listed above.
Today’s complaint investigation was conducted with Elsy Moskito, care giver and later met with Thana Theng

LPA Soto conducted interviews with the S#2 care giver Elsy and Administrator Thana, C#1 - C#4. LPA Soto toured the entire facility with Elsy.The LPA also requested copies of the following documents: Face sheets, mars (August & September), Physician's Report, needs and services plan, and IPP for C#1.

Based on LPA investigation, the investigation revealed the following: For Allegation:Facility walls in disrepair.
Interviews conducted with administrator, she stated that C#1, has never behaved like that before, hitting doors, yelling, and screaming. This was the first time it had ever happened. She asked C#1 if C#! was hurting inside her body, C#1 shook C#1's head "no." Administrator pointed to head, C#1 shook C#1 head, "No." Administrator, could not determine what made C#1 hit the bathroom door. T he wall in C#1 room has a hole where the door knob hit the wall hard and made a hole the size of the door knob.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20210901145313
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: ROSTAR HOME II INC
FACILITY NUMBER: 198602375
VISIT DATE: 09/09/2021
NARRATIVE
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Interviews with S#2, she stated that C#1 was mad at C#2 because C#2 kept talking to C#1 and C#1 got mad at C#2 and kicked the bathroom door several times and cracked the bathroom door. S#2 also stated that C#1 has never done this before. S#2 did not know who or what made the door knob hole. Interviews with C#1 - C#4, they could not tell LPA, who or what made the hole in C#1 room or hit the bathroom door. LPA Soto observed the bathroom door cracked at the bottom right side and the hole in the wall made by the door knob in C#1 room. Interviews conducted and LPA 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 Thana Theng, and a hard copy was provided with the Appeal Rights.




SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20210901145313
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: ROSTAR HOME II INC
FACILITY NUMBER: 198602375
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2021
Section Cited
CCR
80087(a)
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80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This was not met as evidence By: based on observations and interviews wall in C#1 has a hole the size of a door knob and bathroom door has a crack on the bottom right side.
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Administrator to repair or replace bathroom and repair hole in C#1 room wall, she will provide the repair invoice when repairs are complete and picture to LPA Soto by email, fax, or mail by 09/20/21.
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which poses a potential health, safety to persons 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: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4