198602620-11-30-2021-11-AS-MVAO-CCZ2M7-20220329173041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602620
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:16:26 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20211122134716

FACILITY NAME:	LONG BEACH RESIDENTIAL		FACILITY NUMBER:	198602620
ADMINISTRATOR:	BONZON, TED		FACILITY TYPE:	735
ADDRESS:	4201 EAST 10TH STREET		TELEPHONE:	(562) 433-2455
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90804
CAPACITY:	49	CENSUS: 45	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Crystal Barrentios		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility has bed bugs.
Resident Has Lice

INVESTIGATION FINDINGS:

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On 11/30/21 LPA Jade Jordan conducted an Unannounced visit regarding the allegations above.
LPA was met by Facilities Assistant Administrator Crystal Barrentios, and the purpose of the visit was explained.

Investigation Consisted of Interview with Admin, Record Review, and Requested documentation pertinent to the investigation.

Regarding Allegation: Facility has Bed Bugs.
Client 1 (C1) was sent to the hospital by the facility staff, due to a discolored skin patch on lower abdominal area, and itching. The hospital let the facility know that C1 was being treated for scabies, not bed bug bites. C1 has not been discharged and is still residing in the hospital. The Facility has a treatment plan for bedbugs with a pest control company, and reciepts were provided for mattress and beddings that were replaced in the room of C1. Therefore: “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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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-20211122134716

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: LONG BEACH RESIDENTIAL	FACILITY NUMBER: 198602620
	VISIT DATE: 11/30/2021

NARRATIVE

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Regarding Allegation: Facility has lice
Client 2 (C2) was sent to the hospital by facility staff because they were refusing to shower. According to the Reporting Party, C2 was treated for Lice from 11/20/21- 11/27/21. C2 was discharged hospital with no medication prescription, and no other diagnosis. Interviews with Administrator revealed that C2 had lice at the facility, and was self-neglecting, by refusing to shower written warnings were given to C2 including a 30 day notice to quit, due to C2 not following facility house rules. Based on LPA interviews, and record review the LPA finds that 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.

No citations were issued during this visit, and a copy of this report was provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

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