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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603128
Report Date: 06/23/2025
Date Signed: 06/23/2025 05:13:21 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
06/17/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250617084101
FACILITY NAME:AZUSA HOMEFACILITY NUMBER:
198603128
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:722 W 6TH STTELEPHONE:
(626) 633-1610
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:3CENSUS: 3DATE:
06/23/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jose Alderete, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff are not providing basic items to clients
Staff is not providing food of good quality to clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Assistant Administrator and explained the reason for the visit.
The investigation consisted of the following: LPA Margaryan obtained a copies of the staff roster, clients roster, reviewed C1 file and obtained copies relevant documents. Interviews conducted with Administrator, Staff 1 (S1) and Staff 2 (S2), Client 1 (C1) and Client 2 (C2). LPA atemted to interview C3, but C3 didn't answer on LPA's questions. Staff 2 was interviewed over the phone


Continue 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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-20250617084101
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: AZUSA HOME
FACILITY NUMBER: 198603128
VISIT DATE: 06/23/2025
NARRATIVE
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In regard to allegation: Staff are not providing basic items to clients. It was alleged that the home consistently lacks essential hygiene items, such as toilet paper, even after requesting them. The bathroom reportedly does not have a shower curtain.

LPA tour the facility including clients bathroom and observed hand soap and toilet paper in the clients bathroom. LPA also observed shower curtain for clients privacy in the clients bathroom. Additional toilet papers and hygiene supplies observed in the closet located in the dining area. Interviews with Client's C1 and C2 revealed that there is always enough toilet paper and hygiene supplies at the facility. C1 stated they didn't have any concerns about this mater. Interviewed Administrator and staff stated that there are always hygiene supplies and toilet papers at the facility. Interviewed Administrator, S1 and S2 stated that clients never complained about toilet papers or other hygiene supplies.

In regard to allegation: Staff is not providing food of good quality to clients. It was alleged that facility not providing good quality food to clients ( meals are salty, hard or overcooked).There are no snacks or supplementary food for clients and no access to clean drinking water and its effects on client health / stomach pain.

Staff and clients interviewed denied the food not being of good quality, and meals are salty, hard or overcooked. Staff and clients stated that the meals served are of variety and in a good quality. According to Administrator and staff if client refuses a meal, there are alternative meals available to clients. They stated there are always snacks available at the facility and at the time of grocery shopping staff considered on clients request. Interviewed Administrator and staff stated that clients never drink water directly from the faucet. Water is filtered through a "Brita Filter" which is in refrigerator and accessible to all clients. Also there are gallons / bottles of water at the facility. During today's visit, LPA toured the facility including kitchen and observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed meats, fruits, vegetables, eggs, juice, milk and snacks, gallons / bottles of water at the facility. Interviewed C1 and C2 stated that they don't have any complains / concerns about the food and drinking water. Interviewed C1 stated that they have breakfast today at the facility but most of the time they like to eat outside of facility. C1 denied that they have stomach pain because of drinking water directly from the faucet. LPA observed box of drinking water in C1's room.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.


Exit interview held. A copy of the report was provided to Jose Alderete

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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
06/17/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250617084101

FACILITY NAME:AZUSA HOMEFACILITY NUMBER:
198603128
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:722 W 6TH STTELEPHONE:
(626) 633-1610
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:3CENSUS: 3DATE:
06/23/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jose Alderete, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff makes inappropriate comments to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Assistant Administrator and explained the reason for the visit.
The investigation consisted of the following: LPA Margaryan obtained a copies of the staff roster, clients roster, reviewed C1 file and obtained copies relevant documents. Interviews conducted with Administrator, Staff 1 (S1) and Staff 2 (S2), Client 1 (C1) and Client 2 (C2). LPA atemt ed to interview C3, but C3 didn't answer on LPA's questions. Staff 2 was interviewed over the phone.


Continue 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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-20250617084101
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: AZUSA HOME
FACILITY NUMBER: 198603128
VISIT DATE: 06/23/2025
NARRATIVE
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In regard the allegation. Staff makes inappropriate comments to clients. It was alleged that staff (S2) has made inappropriate comments to C1 such as who C1 is having sexual relations with and if C1 has had sex before. This made C1 feel extremely uncomfortable and C1 does their best to avoid S2 when S2 is working.

Interviewed Administrator and S1 stated that as of this morning 06/23/25 they were not aware of that S2 had an inappropriate conversation with C1 about C1's sex life. Interviewed Administrator and S1 stated that they did not witness of conversation but this morning C1 told S1 that S2 made inappropriate comments about C1's sexual activity and it made C1 feel very uncomfortable. Interviewed Administrator stated there is currently an open investigation in different home with the similar allegation that S2 involved, and it is under SGPRC and facility investigation. Administrator stated that S2 currently suspended from the work until end of the investigation. Interviewed C1 stated that S2 made them very uncomfortable with the question that S2 ask about C1's sexual life. C1 stated that they brought S1's attention this morning. LPA spoke with S2 over the phone and S2 admitted that they ask questions to C1 about C1's sexual life and ask if C1 has had a sex before.

Based on LPA’s interviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

Based on LPA's interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.


See the attached 9099 D

Exit interview held. A copy of the report and appeal rights were provided to Jose Alderete
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250617084101
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: AZUSA HOME
FACILITY NUMBER: 198603128
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/27/2025
Section Cited
CCR
80072(a)(2)
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(a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Administrator shall provide a copy of In-service for all staff regarding "Personal Rights," by POC due date 06/27/25. Proof of correction will be email to LPA.
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This requirement is not met as evidenced by: Investigation has revealed that a S2 made inappropriate comments towards C1, which made C1 very uncomfortable. This poses a potential health and safety risk to the clients 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: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5