198603021-1-7-2025-28-AS-TVAO-DCWVRM-20250114154011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603021
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:53:27 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/02/2025 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250102091448

FACILITY NAME:	FAMILY HOME LLC		FACILITY NUMBER:	198603021
ADMINISTRATOR:	VILLALVA, JOEL H		FACILITY TYPE:	740
ADDRESS:	1629 CALLE CIERVO		TELEPHONE:	(626) 354-0265
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 3	DATE:	01/07/2025
		UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Latai Tuihalamak (Tai) , DSP and Joel Villava, Administrator		TIME COMPLETED:	01:57 PM

ALLEGATION(S):

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Administrator engaged in an altercation with a staff in the presence of the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made initial unannounced visit to investigate the above allegation. LPA met with Latai Tuihalamak (Tai) DSP and Administrator Joel Villalva showed up a short time later.

The investigation consisted of LPA interviewing three (3) staff (S#1-S#3) and three (3) residents (R#1-R#3). LPA took tour of facility.
Allegation: Administrator engaged in an altercation with a staff in the presence of the residents. It is alleged that Administrator engaged in altercation with staff in resident’s presence.
The investigation revealed that on 01/01/2025 around 1-2pm, S#3 arrived at facility and observed the Christmas tree on the ground in the living room and told S1 that he will go get a box to store it. Not to put in the garage. S1 was concerned that the tree was causing an obstruction and hazard to residents and took the tree to the garage.
(Continued on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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 28-AS-20250102091448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAMILY HOME LLC	FACILITY NUMBER: 198603021
	VISIT DATE: 01/07/2025

NARRATIVE

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(Continued to from 9099)

Around 20 minutes later, S3 returned to facility and slammed the table (S#3 demonstrated how S3 slammed the table and stated it sounds loud because it is a loud table) in the dinning/living room because S3 stated he was having a bad day. Three (3) of three (3) staff were able to corroborate the allegation. One (1) of three (3) residents were able to corroborate the allegation. One resident could not recall anything happening on 01/01/2025 and one (1) resident was unable to answer questions. One resident stated it was not appropriate and was able to hear the slamming from resident's room. One (1) resident stated that S3 was yelling at S1 and apologized after saying I’m sorry, I’m sorry.

Based on interviews with staff and residents, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250102091448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAMILY HOME LLC	FACILITY NUMBER: 198603021
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/10/2025 Section Cited CCR 87468.1(a)(1)(3)	1 2 3 4 5 6 7	87468.1(a)(1)(3) Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will read section 87468.1 (a)(1)(3) and send a written statement to LPA certifying that he has read the section and understands it by POC date which is 01/10/2025. Administrator will also attend training on section 87468.1 for himself and staff and send copies of rosters with signatures for those in attendance.
	8 9 10 11 12 13 14	S3 slammed table inappropriately, and yelled at S1 in presence of residents. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC9099 (FAS) - (06/04)

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