198603180-4-3-2025-28-AS-RORN-DFLLJB-20250410084739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603180
Report Date: 04/03/2025
Date Signed: 04/03/2025 12:25:01 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
03/10/2025 and conducted by Evaluator Christian Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250310220423

FACILITY NAME:	RAECHELLE CARE HOME		FACILITY NUMBER:	198603180
ADMINISTRATOR:	BERG, TIA		FACILITY TYPE:	735
ADDRESS:	2215 W 15TH ST		TELEPHONE:	(323) 656-8266
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90006
CAPACITY:	30	CENSUS: 24	DATE:	04/03/2025
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Ronnie Burchette		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff mishandle a client's medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Ronnie Burchette Office Manager and explained the purpose of the visit. Administrator Tia Berg was notified by telephone.

The investigation consisted of the following: During the initial visit conducted on 03/13/2025, LPA interviewed staff #1, and obtained copies by email of the following documents: staff roster, client roster, C1’s admission agreement, identification, and emergency information LIC 601, preplacement appraisal, physicians report, client’s personal property and valuables, copy of medication list, and hospital discharge paperwork. During today’s visit LPA interviewed staff S2-S3, and clients C2-C5. LPA attempted to interview C1 but was unsuccessful. LPA obtained new MAR log and hospital assessment.

SEE LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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-20250310220423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAECHELLE CARE HOME	FACILITY NUMBER: 198603180
	VISIT DATE: 04/03/2025

NARRATIVE

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In regard to the allegation” Staff mishandle a client's medications”, Its is alleged that C1 is not receiving medication regularly although medication has been prescribed. The investigation reveled that during the time of visit LPA Gutierrez observed the Mar log only had five (5) medications listed and after reviewing documents there were two (2) separate orders from hospital dated 01/04/2025, and 02/11/2025 with a list of current medications that facility did not have. During interview with S1 it was reveled that paperwork was not reviewed and C1 did not have current medications at facility. S1 stated “I let it slip by me I messed up”.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Office Manager Ronnie Burchette. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20250310220423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAECHELLE CARE HOME	FACILITY NUMBER: 198603180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/04/2025 Section Cited CCR 85075(B)	1 2 3 4 5 6 7	85075 Health-Related Services (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.	1 2 3 4 5 6 7	Facility contacted pharmacy and filled all clients prescriptions. Administrator will go over training with staff and send LPA training log by POC due date.
	8 9 10 11 12 13 14	This deficiency is evidenced by the following: Facility did not insure client had all medication that was prescribed by physician. This poses an immediate health and safety risk to clients 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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
03/10/2025 and conducted by Evaluator Christian Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250310220423

FACILITY NAME:	RAECHELLE CARE HOME		FACILITY NUMBER:	198603180
ADMINISTRATOR:	BERG, TIA		FACILITY TYPE:	735
ADDRESS:	2215 W 15TH ST		TELEPHONE:	(323) 656-8266
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90006
CAPACITY:	30	CENSUS: 24	DATE:	04/03/2025
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Ronnie Burchette		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff do not safeguard a client's personal belongings
Staff are withholding food from a client
Staff are yelling at a client

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20250310220423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAECHELLE CARE HOME	FACILITY NUMBER: 198603180
	VISIT DATE: 04/03/2025

NARRATIVE

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In regard to the allegation “Staff do not safeguard a client's personal belongings”, it is alleged that staff are stealing items. During interviews with clients four (4) out of five (5) have never had any items stolen by staff. During interviews with staff three (3) out of three (3) staff deny ever stealing from clients. S3 stated the only thing ever taken from a client’s room was liquid bleach and laundry detergent because they can’t have that in their rooms. C1 had refused to sign LIC 621 Client Personal Property and Valuables sheet at time of admission.

In regard to the allegation “Staff are withholding food from a client”, it is alleged that staff is withholding food from clients. During interviews with clients four (4) out of five (5) stated that they never had food withheld from them. During interviews from staff three (3) out of three (3) deny ever with holding food from clients. S1 stated that C1 thinks they withhold food because there are set times for breakfast, lunch, and dinner. S1 also stated special accommodations are made for when C1 leaves for dialysis to ensure food is served.

In regard to the allegation “Staff are yelling at a client”, It is alleged that staff yell at clients. During interviews with clients four (4) out of five (5) stated that staff does not yell at them. During interviews with staff three (3) out of three (3) deny yelling at clients. S3 stated that she only says, “No smoking in your rooms only outside”.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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.

An exit interview was conducted with Office Manager Ronnie Burchette. A copy of the report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5