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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603474
Report Date: 09/21/2022
Date Signed: 09/21/2022 01:31:03 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
09/15/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220915150931
FACILITY NAME:HELIOFACILITY NUMBER:
198603474
ADMINISTRATOR:MARCELO, TAJFACILITY TYPE:
735
ADDRESS:510 FOXPARK DRIVETELEPHONE:
(929) 429-0836
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:4CENSUS: 4DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Connie Mitchell TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff provoke clients.
Facility sofa causes clients to have skin irritation.
Facility does not provide clients with hygiene products.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit to investigate the above allegations. LPA met with Connie Mitchell and disussed the purpose of today's visit.

During the course of this investigation, LPA obtained a copy of the Client Roster, a copy of the Staff Roster, interviewed the Facility Administrator/S-1, Staff #2 (S-2), Staff #3 (S-3), Client #3 (C-3) and Client #4 (C-4). LPA was unable to interview C-1 and C-2 as they did not understand the interview questions. LPA also obtained a copy of the facility menu and conducted a facility tour.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 5
Control Number 28-AS-20220915150931
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: HELIO
FACILITY NUMBER: 198603474
VISIT DATE: 09/21/2022
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
Allegation: Staff provoke clients. Interviewed staff indicated they have not witnessed any staff (including S-3) provoking clients. Interviewed staff indicated they have not received any complaints/concerns in regards to staff provoking clients. Staff interviews revealed (1) out of (4) clients has a history of being admitted into a 50/51 hospital admission due to danger to self or others. Per staff, staff are not provoking clients into 50-51 hospital admissions. LPA was unable to interview C-1 and C-2 as they did not understand the interview questions. (1) of (2) interviewed clients indicated they have a history of 51/50 admissions which are unprovoked by staff. Staff and client interviews do not corroborate this allegation.

Allegation: Facility sofa causes clients to have skin irritation. Interviewed staff indicated they have not received any complaints/concerns in regards to the facility sofa causing clients to have skin irritation. Interviewed staff indicated that the sofa cushion covers are washed on a weekly basis and are sanitized on a daily basis. Staff interviews revealed that (1) out of (4) clients has been and continues to be treated for skin irritation by a physician (as the skin irritation occurs off and on). Per staff interviews, there are no insects in or on the sofas. LPA conducted a facility tour and did not observe any insects on the sofas. LPA was unable to interview C-1 and C-2 as they did not understand the interview questions. (1) of (2) interviewed clients indicated they are being treated for a rash (off and on) for a couple of months (not related to the sofa). Staff interviews, client interviews and observation (sofa) do not corroborate this allegation.

Allegation: Facility does not provide clients with hygiene products. Staff interviews revealed that the clients are provided with hygiene products (included with their board and care service). Interviewed staff indicated that each client has their own plastic cubby with hygiene products. Per staff interviews, clients are provided with shampoo, conditioner, body wash, body lotion, toothbrush and toothpaste, deodorant, feminine products, incontinence supplies and so forth. LPA conducted a facility tour and observed each clients hygiene cubby and additional hygiene supplies stored inside the garage. LPA was unable to interview C-1 and C-2 as they did not understand the interview questions. Interviewed clients confirmed that they have their own cubby with hygiene supplies and are aware that the facility provides the hygiene products. Staff interviews, client interviews and observation (hygiene products) do not corroborate this allegation.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated Exit interview was conducted and a copy of this report and appeal rights were provided to Connie Mitchell.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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
09/15/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220915150931

FACILITY NAME:HELIOFACILITY NUMBER:
198603474
ADMINISTRATOR:MARCELO, TAJFACILITY TYPE:
735
ADDRESS:510 FOXPARK DRIVETELEPHONE:
(929) 429-0836
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:4CENSUS: 4DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Connie Mitchell TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not follow menu.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit to investigate the above allegations. LPA met with Connie Mitchell and disussed the purpose of today's visit.

During the course of this investigation, LPA obtained a copy of the Client Roster, a copy of the Staff Roster, interviewed the Facility Administrator/S-1, Staff #2 (S-2), Staff #3 (S-3), Client #3 (C-3) and Client #4 (C-4). LPA was unable to interview C-1 and C-2 as they did not understand the interview questions. LPA also obtained a copy of the facility menu and conducted a facility tour.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220915150931
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: HELIO
FACILITY NUMBER: 198603474
VISIT DATE: 09/21/2022
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
Allegation: Staff do not follow menu. Interviewed staff indicated they try to follow the menu as much as possible. (1) interviewed staff indicated that they “try” to obtain the food items necessary to follow the menu. Staff interviews revealed that a variety of food is provided to clients when the supply to follow the menu is in stock at the facility. LPA conducted a facility tour and inspected both refrigerators (kitchen and garage) for necessary food items to prepare meals for (3) consecutive days (Wednesday, Thursday and Friday) of this week. LPA discovered that this facility did not have the food inventory to meet with meals noted on the menu. Staff interviews and observation (food inventory) corroborates this allegation.

Based on interviews conducted and LPA observations, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22.

Exit interview was conducted and a copy of this report and appeal rights were provided to Connie Mitchell.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220915150931
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: HELIO
FACILITY NUMBER: 198603474
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2022
Section Cited
CCR
80076(a)(1)
1
2
3
4
5
6
7
Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected,
1
2
3
4
5
6
7
Administrator to purchase food supplies to meet the facility food menu and provide a copy of the receipt(s). Administrator to also submit a written statement as to how staff will ensure the food supply is readibly in stock to prepare the meals noted on the facility food menu and submit this information to LPA by POC due date of 09/22/22.
8
9
10
11
12
13
14
stored, prepared and served in a safe and healthful manner. This standard is not met as evidence by: Per staff, they try to follow the menu as not all food items are in stock in the facility to follow the menu. LPA inspected both refrigerators and discovered that this facility did not have the food inventory to meet the food menu.
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.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5