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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602619
Report Date: 09/02/2021
Date Signed: 09/02/2021 10:29:10 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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210813145045
FACILITY NAME:ACOSTA FAMILY HOME IIIFACILITY NUMBER:
198602619
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:875 S ARANBE AVETELEPHONE:
(310) 554-4824
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY:6CENSUS: 2DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Ashley AcostaTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Untrained staff
Facility is operating out of ratio
Illegal Eviction
INVESTIGATION FINDINGS:
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On 9/2/21 at Licensing Program Analyst (LPA) Martessa Brown a subsequent visit in order to render investigation findings for the above allegations. LPA met with Ashley Acosta, the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 8/17/21, Licensing Program Analyst (LPA) Martessa Brown initiated the 10-Day visit and met with Ashley Acosta, the facility administrator. LPA conducted a Health and safety check. LPA toured the facility physical plant. No clients were not at the facility due to being at the day program. LPA reviewed staff #1-2 records, clients #1-2 records, staff #1-2 records and conducted interview with the administrator regarding the above allegation.

The investigation revealed the following:

LIC 9099 is on the next page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 5
Control Number 11-AS-20210813145045
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: ACOSTA FAMILY HOME III
FACILITY NUMBER: 198602619
VISIT DATE: 09/02/2021
NARRATIVE
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Regarding Allegation: Untrained staff

On 8/16/21, LPA interviewed the reporting party regarding the above allegation. She stated there was an altercation between C1 & C3. She stated staff were not trained to handle the situation and clients were sent their room. On 8/17/21 -9/2/21 LPA interviewed the Administrator and staff S1-S2 regarding the above allegation. Administrator and staff stated there was an incident between C1 & C3 but they were able to de-escalate the situation. Based record reviewed staff S1, S2 and Administrators training record was not current.

Regarding Allegation: Facility is operating out of ratio

On 8/16/21, LPA interviewed the reporting party regarding the above allegation. She stated when she was at the facility in February that S2 was only one there with 4 clients 4pm -12 pm. On 8/17/21 -9/2/21 LPA interviewed the Administrator and staff S1-S2 regarding the above allegation. Administrator and staff stated there is two staff available to clients. Administrator stated herself and S1 are there in the daytime. S1 and S2 also stated there is 2 staff during shifts. Based on interviews and time sheets review that Administrator was working am shift with staff and one staff working from 12 PM-4 PM.

Regarding Allegation: Illegal Eviction

On 8/16/21 LPA interviewed the reporting party regarding the above allegation. She stated C1 and C2 were Illegally evicted. She stated the administrator is evicting C1 and C2 due to her being involved with the client’s well-being. She stated the administrator doesn’t like her involvement and doesn’t answer her calls when she checks on them. She stated administrator had to move them.

LIC-9099 is on the next page.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20210813145045
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: ACOSTA FAMILY HOME III
FACILITY NUMBER: 198602619
VISIT DATE: 09/02/2021
NARRATIVE
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On 8/17/21, LPA interviewed administrator regarding the above allegation. She stated Clients C1 and C2 were given a 30-day eviction notice on 8/13/2021. She stated client’s conservator would always come to the facility and not abiding Covid-19 visitation guidelines. She stated the when the Conservator come to the facility or calls C1-C2 will get disruptive. She stated eviction notice was issued on 8/12/21. On 8/20/2021, LPA received an amendment of the eviction notices for C1-C2. Based on interviews conducted and documents review the administrator did not follow Title 22’s eviction procedures, clients evicted for conservator and not house rules.

LPA did not interview Clients C1-C3 due to them not being able to communicate. On 9/28/21, LPA Brown attempted to interview Client C4, but client did not want to continue with investigation

Substantiated: Based on Investigators interviews which were conducted with reporting party, administrator and records review, 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) are being cited on the attached LIC9099-D.

Exit interview conducted, appeal rights were discussed, and a copy of this report was provided to Ashley Acosta, the Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210813145045
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: ACOSTA FAMILY HOME III
FACILITY NUMBER: 198602619
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2021
Section Cited
CCR
85065.5(a)(1)
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85065.5 Day Staff Client Ratio
(a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met:
(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center…
This requirement was not met as evidence by:
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Administrator will ensure staffing ratio to clients is maintain according to the regulation outline in title 22. Administrator will submit a completed personnel report to LPA and a plan to ensure how staffing ratio will be met to LPA Brown poc due date 9/13/21.
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Based on interviews and records reviewed the administrator did not adhere to staff ratio to clients. Timesheet indicated there was 1 staff working between the hours of 4PM-12PM.
This poses a potential Health and Safety risk to residents in care.
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Type B
09/13/2021
Section Cited
CCR
85022(b)
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85022 Plan of Operation
(b) The plan of operation shall contain written evidence of arrangements for any consultants and community resources which are to be utilized to meet regulatory requirements or requirements of the facility's plan of operation.

This requirement was not met as evidence by:
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Administrator will submit a plan on how and when she will have all staff training up to date according to plan of operation. Administrator will sent to LPA Brown by poc due date 9/13/21.
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Based on interviews and records review. The plan of operation indicated staff was to have CPI training. LPA did not observe staff training for S1-S2.
This poses a potential Health & Safety risk to residents 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: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210813145045
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: ACOSTA FAMILY HOME III
FACILITY NUMBER: 198602619
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2021
Section Cited
CCR
85068.5(a)
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85068.5 Eviction Procedures
(a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit for any of the following reasons:
This requirement is not met as evidence by:
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Administrator will rescind eviction notice regarding C1-C2 and will send a letter to LPA that she read regulations and to ensure the guidelines of the eviction process in Title 22. Administrator will send copies by poc due date 9/13/21 to LPA's M. Brown attention.
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Based on interviews conducted and records reviewed client’s admission agreement, C1-C2 were not evicted according to Title 22’s eviction procedure. LPA reviewed the eviction notice and there was no indication that clients broke house rules but being evicted due to conservator. This poses a potential Health and Safety risk to residents 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: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5