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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602601
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:03:14 PM

Unsubstantiated


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
04/20/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220420095748
FACILITY NAME:DEL SOL HOME (BEACH)FACILITY NUMBER:
198602601
ADMINISTRATOR:GONZALES, MERCI CANIAFACILITY TYPE:
735
ADDRESS:10248 BEACH STTELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:4CENSUS: 4DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Merci Gonzales (Administrator)TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained unexplained bruises while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA meet with Merci Gonzales (Administrator) and explained the purpose of the visit.

During today's visit LPA obtained and reviewed a copy of the Staff/Client Rosters, Client #1's records (Facesheet, Physician's report, Conservator information, Individual Service Plan, Behavior Assessment, Behavior data sheet, Medication record), interviewed Staff #1 to Staff #8 in the dining area between 9:20 am to 10:54 am, interviewed Clients #3 in the bedroom at 11:10 am.

In regards to the allegation: Resident sustained unexplained bruises while in care. LPA's interview Staff which indicated Client #1 was taken to the hospital on 04/18/22. Prior to Client #1 being taken to the hospital, 6 of 8 Staff interviewed did not observed bruising on Client #1 and the remaining 2 Staff indicated that Client #1 had a bruise on top of the left hand. After Client #1 return to the facility from the hospital on 04/21/22, a body check was performed by Staff and Staff noticed multiple bruising on both Client #1's arms and leg. Continue to LIC9099C....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 5
Control Number 28-AS-20220420095748
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: DEL SOL HOME (BEACH)
FACILITY NUMBER: 198602601
VISIT DATE: 04/22/2022
NARRATIVE
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Review of Client #1's records indicate that Client #1 has self injury behaviors such as biting and scratching. A review of Client #1's medication records included epilepsy medications such as Lamotrigine and Keppra with side effects of easy bruising.

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

Exit interview conducted with Merci Gonzales (Administrator) and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/20/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220420095748

FACILITY NAME:DEL SOL HOME (BEACH)FACILITY NUMBER:
198602601
ADMINISTRATOR:GONZALES, MERCI CANIAFACILITY TYPE:
735
ADDRESS:10248 BEACH STTELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:4CENSUS: 4DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Merci Gonzales (Administrator)TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff shaved resident's pubic area without authorization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA meet with Merci Gonzales (Administrator) and explained the purpose of the visit.

During today's visit LPA obtained and reviewed a copy of the Staff/Client Rosters, Client #1's records (Facesheet, Physician's report, Conservator information, Individual Service Plan, Behavior Assessment, Behavior data sheet, Medication record), interviewed Staff #1 to Staff #8 in the dining area between 9:20 am to 10:54 am, interviewed Clients #3 in the bedroom at 11:10 am.

In regards to the allegation: Staff shaved resident's pubic area without authorization. Interviews with 3 of 8 Staff indicated that Client #1's pubic area was shaved/trimmed without authorization from the Conservator. Staff indicated that Client #1's pubic area was shaved/trimmed in order to prevent infection (Urinary tract infection) and was not aware that authorization from the Conservator was needed. Interview with Witness also indicated that Clients #1's pubic area was shaved/trimmed without authorization from the Conservator. Continue to LIC9099C....
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 5
Control Number 28-AS-20220420095748
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: DEL SOL HOME (BEACH)
FACILITY NUMBER: 198602601
VISIT DATE: 04/22/2022
NARRATIVE
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Based on LPA's interviews, investigation for the above allegation revealed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Merci Gonzales (Administrator) and a copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220420095748
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: DEL SOL HOME (BEACH)
FACILITY NUMBER: 198602601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Licensee shall provide additional training to all staff to ensure that authorization from either the Client or their Conservators is provided in order for Staff to perform services such as shaving/trimming of Clients pubic area. Licensee shall provide proof of training to the department by the POC date.
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This requirement is not met as evidenced by: Interviews with 3 of 8 Staff indicated that Client #1's pubic area was shaved/trimmed without authorization from the Conservator. Staff indicated that Client #1's pubic area was shaved/trimmed in order to prevent infection (Urinary tract infection) and was not aware that authorization from the Conservator was needed. Interview with Witness also indicated that Clients #1's pubic area was shaved/trimmed without authorization from the Conservator.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5