<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603201
Report Date: 08/29/2022
Date Signed: 10/21/2022 10:46:57 AM

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 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
12/31/2021 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211231164706
FACILITY NAME:HEART TO HOME RESIDENTIAL FACILTYFACILITY NUMBER:
198603201
ADMINISTRATOR:MINES, JASMINEFACILITY TYPE:
735
ADDRESS:795 E ELIZABETH STTELEPHONE:
(626) 233-0725
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:6CENSUS: 3DATE:
08/29/2022
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Hazel Gatan, AdministratorTIME COMPLETED:
05:21 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility refuses to accept resident back from ER
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
************This report dated 8/29/2022 is being amended to remove confidential names and phone numbers. No other information is being changed. Investigation findings on this report remain the same.****************

Licensing Program Analyst (LPA) Bennette Pena conducted a second subsequent unannounced visit to the facility to continue the investigation of the complaint and deliver findings. Upon arrival, LPA met with Adm and explained the purpose of the visit.

During the initial visit conducted by LPA Bennette Pena on 8/22/2022, LPA obtained copies of the current Staff and Client Roster, Admission Agreement and IPP for 4 clients, conversation timeline between Adm and Hospital regarding clients' release process and Incident report submitted on 12/29/2021. LPA also interviewed two (2) Direct Support Professional (DSP) Staff #1 (S1) and Staff #2 (S2) and Adm.The interviews conducted were regarding the Covid Mitigation plans, procedures and eviction regulations.

During today's visit, LPA Pena tried to obtain copies of Client #1 (C1) files, Medical Assessments, Huntington Hospital Discharge Papers, Eviction notice. LPA interviewed Adm and S3 on the phone.

Continued on LIC9099-C..........
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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 4
Control Number 28-AS-20211231164706
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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201
VISIT DATE: 08/29/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding allegation: Facility refuses to accept resident back from ER

LPA’s interview with the Adm confirmed that C1 was admitted to the Huntington Hospital ER on 12/29/21 for a 5150 hold by the Pasadena Police Department (police report number unknown, officer name unknown). Adm stated that C1 was being aggressive and physical with a staff. She stated that she received a phone call from W4 on 12/31/2021 and was told that C1 did not qualify for a 51/50 hold and was being released. Adm told W4 that she will not accept C1 back due to the health and safety of other clients and staff in the facility. Adm stated that S3 was aware of the situation and both of them agreed not to take C1 back. Adm also mentioned that their BCBA recommended a temporary placement for C1. Adm stated that she issued an eviction notice prior to C1's hospitalization but could not provide any documentation. The eviction notice was sent to Frank Lanterman Regional Center but did not send a copy to CCLD.

The investigation consisted of a phone call to W1. W1 confirmed the allegation that the facility refused to take the client back to the facility. Investigation was done by the Regional Center. The reason given to her by Adm was due to the client being a danger to himself and for the health and safety of the other clients and staff at the facility. C1 is sharing a room with another client. W1 contacted W2 and had a meeting regarding finding a temporary placement for C1. W2 spoke to the Social Worker at the Hospital to asked that they hold C1 in the Hospital until they find a temporary placement for him after the holidays. Unbeknownst to them, C1 contacted W3 to come and pick him up. He was picked up by W3 from the Hospital.

Interviews with two (2) staff revealed that they did not see C1 back at the facility after he was admitted to the Hospital. They were unaware of what happened and did not know if he was denied back at the facility.

Continued on LIC9099-C.....
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20211231164706
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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201
VISIT DATE: 08/29/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA attempted to interview S3 and left a voicemail message. Call was returned on 8/29/2022. At 4:24pm, S3 and Adm called LPA for a 3-way conversation. S3 stated that she refused C1 back due to 2 reasons. One of the reasons was he needed to be quarantined per Pasadena Public Health Dept. guidelines. However, there was no proof that C1 was tested Covid positive at the time. Second reason was he was a danger to himself and a threat to the health and safety of other clients and staff at the facility.

Based on LPA's observations, review of records and interviews conducted, 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, Section cited 85068.5(a)(1-5) is being cited on the attached LIC 9099D.

Exit interview held. A copy of the report, deficiency citation and appeals rights were provided to Kenia Williams, House Manager.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 28-AS-20211231164706
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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2022
Section Cited
CCR
85068.5(a)(1-5)
1
2
3
4
5
6
7
85068.5 Eviction Procedures
(a) The licensee shall...evict a client...with a 30-day written notice to quit for any of the following reasons: (1) Nonpayment of the rate ..(2) Failure of the client to comply.....of the alleged violation. (3)Failure of the client to comply...in the Admission Agreement. (4) ..... as specified in Section 85068.3, which determined that the client's needs cannot be met by the facility and the client has been given an opportunity to relocate as specified in Section 85068.3(b)(3). 5) hange of use of the facility.

1
2
3
4
5
6
7
Licensee and Administrator agreed to read and review CCR Title 22, Division 6 Chapter 6
Article 06. 85068.5
Eviction Procedures.
8
9
10
11
12
13
14
Based on documents reviewed and interviews, Administrator and licensee refused to accept a client back to the facility after being released from the Hospital which was a violation of client's personal rights.
8
9
10
11
12
13
14
Both Licensee and Administrator will send a signed statement to LPA that they have read, reviewed and understood the Eviction Procedures by POC due date. It can be emailed or faxed to LPA Pena.
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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4