198602568-10-27-2021-11-AS-MCAA-C8FVGV-20211104162610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602568
Report Date: 10/27/2021
Date Signed: 10/27/2021 01:33:38 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20211021132421

FACILITY NAME:	MOM & DAD'S HOUSE-COTTAGE		FACILITY NUMBER:	198602568
ADMINISTRATOR:	MEADER, IVONNE A		FACILITY TYPE:	740
ADDRESS:	5413 E CONANT ST		TELEPHONE:	(949) 381-1792
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	10/27/2021
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Yvonne Meader		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff do not keep facility free of trash.

INVESTIGATION FINDINGS:

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On 10/27/21 Licensing Program Analyst (LPA) Jade Jordan made an unannouced complaint visit, to investigate the allegation above. LPA Met with Administrator, and the purpose of the visit was explained.

The investigation consisted of the following: Physical Plant tour Exterior and Interior, Interviews with staff/residents, resident family member, and requested copies staff and resident rosters.

Regarding Allegation " Staff do not Keep Facility free of trash"

Upon Entry Lpa observed a fenced front yard, with a swing gate leading to the front door. Fence and swing gate seclude the house away from public resdential side walk. Front lanscaping/greenery was free of trash and debris. Once inside, Lpa conducted a Physical Plant Tour with the assistance of Staff Jovanni. LPA, and staff inpected, and obsereved the interior and exterior perimeters of the facility, including the backyard. The facility is a 6 bed room home, located in a residential neighborhood. LPA observed all rooms in the interior to clean, free of trash, and had no odor.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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 11-AS-20211021132421

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: MOM & DAD'S HOUSE-COTTAGE	FACILITY NUMBER: 198602568
	VISIT DATE: 10/27/2021

NARRATIVE

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To the left of the facility, there is a alley that wraps around toward surrouding homes, and is permitered by landscaping, no trash or debris were observed, on the side of the facility. LPA observed Neighborhood trash cans, including the facility that are placed in the alley, for trash pick up. The alley is shared by other neighboring homes. LPA Interviewed Residents 1-4, and a residents visting family member, All generally stated that that they have not seen any loitering of trash, in or around the facility perimeters.

Based on LPA observation, and interviews Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and a copy of this report was provided. No citations were issued during this
visit.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC9099 (FAS) - (06/04)

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