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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603410
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:48:55 PM



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
11/04/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211104093231
FACILITY NAME:LA CASITA RESIDENTIAL CARE INC.FACILITY NUMBER:
198603410
ADMINISTRATOR:SANTAMARIA, HUMBERTOFACILITY TYPE:
740
ADDRESS:700 N. GRAND AVE.TELEPHONE:
(626) 387-9987
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 6DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Humberto Santamaria TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is over capacity.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Jewel Baptiste and Angelica Rea conducted an unannounced visit in response to the above allegation. LPAs met with caregiver Hilda Leon and was later met with administrator Humberto Santamaria and discussed the reason for the visit. LPA interviewed Administrator, staff #1- staff #3, toured the facility and obtained copies of the resident roster..

Regarding the above allegation: Facility is over capacity, the investigation revealed that there were at least 7 residents residing at the facility until October 2021. 3 out of 4 staff interviewed stated that they currently have 6 residents, but sometimes they will have an extra person doing "daycare" to see see if resident and family like the facility. According to staff the "extra person" will sometimes spend the night. Resident roster also shows 7 residents living at the facility until October 2021.

On 11/9/2021, LPAs also observed the following: 4 bedrooms with 1 bed, 1 bedrom with 2 beds, and 1 bedroom with 0 bed and a chair. LPAs took photos of the bedrooms during visit.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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 3
Control Number 28-AS-20211104093231
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: LA CASITA RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603410
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2021
Section Cited
CCR
87202(a)
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Fire Clearance
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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Administrator will ensure that the facility will abide by fire clearance and operate within licensing regulations. Administrator shall review section 87202 and provide a wrriten statement stating that he understands and will follow the regulation.
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This requirement was not met as evidenced by:

LPAs learned through interviews with 3 out of 4 staff, and review of resident roster that the facility had 7 residents up until Oct 2021. Also the facility fire clearance is approved for only 6 residents. This poses a health and safety risk to residence 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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20211104093231
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: LA CASITA RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603410
VISIT DATE: 11/09/2021
NARRATIVE
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Based on interviews conducted and documents received the, preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of regulations Title 22, Divison 6 are being cited on the attached LIC 9099D

An exit interview was conducted with Administrator, copy of report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3