198602568-12-13-2021-11-AS-MCAA-C9Y34Y-20211222165556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602568
Report Date: 12/09/2021
Date Signed: 12/13/2021 09:44:50 AM

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
12/06/2021 and conducted by Evaluator Susan Campos

COMPLAINT CONTROL NUMBER: 11-AS-20211206152918

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:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Ivonne Meader		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility has pests

INVESTIGATION FINDINGS:

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On 12/9/2021 at 8:35 a.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Ivonne Meader. LPA explained to Ms. Meader the purpose of the visit. The investigation consisted of the following: LPA conducted interviews on 12/9/21 with (5) staff member (6) residents, and the facility pest control technician. In addition, on 12/9/21, LPA and Ms. Meader conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. LPA also reviewed the following documents provided by Mom & Dad’s House-Cottage Administrator Ivonne Meader: LIC 500-staff roster, client roster, staff schedule, Incident Reports from November 2021 to present, Internal staff incident reports from November 2021 to present, House Rules, Facility Cleaning/ Disinfection Procedures, Facility Pest control prevention and elimination procedures, and Pest Technician reports for 11/30/21 and 12/9/21.

Report continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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-20211206152918

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: 12/09/2021

NARRATIVE

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Investigation

Allegation: Facility has pests

The investigation revealed, per LPA interviews, with (5) staff members, (6) residents from the Mom & Dad’s House Cottage facility, pest control technician, and also review of facility documents, that the facility does not have pests. S1 informed LPA, that S1 and S2 were informed by S3, per email, on 11/29/21, that during NOC work shift, S3 saw a mouse in the kitchen. S1 and S2 visited the facility, the next day, 11/30/21 at 6:30 am, and investigated the kitchen area, where the mouse was observed, and also S2 contacted the facility Pest Control Technician, and followed up with the pest control technician directions, that included immediately covering up the hole, in the bottom cabinet, with pest control foam, setting mouse traps, sticky paper, and also installing a sonar mice elimination device, in the kitchen area, and other parts of the house. Also S2 states, that once the pest control measures were in place, in the kitchen area, the mouse never returned after the 11/29/21 reported staff sighting. In addition, S1 informed the LPA, that the pest control technician visited the facility on 12/9/21, and confirmed that the mouse is no longer in the facility, and also that there have not been any reports, from staff or residents, of a mouse sighting, in the facility, since the corrective measures were installed on 11/30/21. The LPA also interviewed 5 facility staff personnel, and 4 of the 5 staff personnel interviewed, informed the LPA that they have never seen a mouse in the facility. In addition, the LPA interviewed (6) residents, and 6 of 6 residents interviewed, informed the LPA, that the staff assist them with their daily care needs, and also 6 of 6 residents informed the LPA, that the staff are available to them when needed. The LPA observed, in the facility kitchen bottom cabinet, mice foam, mice traps, sticky paper, and a mice sonar device. In addition, the LPA interviewed, the facility pest control technician, and was informed, that there are no mice in the facility.

Based on information gathered, LPA did not find sufficient evidence to support allegation "Facility has Pests”

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. No citations issued. An exit interview was conducted with Ivonne Meader, Administrator, and a hard copy of a LIC 9099 was provided.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC9099 (FAS) - (06/04)

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