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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603525
Report Date: 07/17/2025
Date Signed: 07/17/2025 05:15:20 PM

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
07/10/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250710144339
FACILITY NAME:LAMBERT PLACE, THEFACILITY NUMBER:
198603525
ADMINISTRATOR:ALVAREZ, EDUARDOFACILITY TYPE:
737
ADDRESS:13304 LAMBERT RDTELEPHONE:
(909) 631-8521
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:3CENSUS: 3DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eduardo Alvarez, AdministratorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Staff mismanage resident's medication.
Staff do not keep the facility free of pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator Eduardo Alvarez.

The investigation consisted of: A physical plant tour of the interior and exterior grounds was conducted, with special focus on insects/ants. Staff (S1- S9) and resident (R1) was interviewed. Interviews with residents (R2-R3) were attempted. Record review of medication administration records, Therap Notes, and R1 & R2's file documents was completed. Relevant documents were reviewed and obtained.

*See next page for narrative.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 3
Control Number 28-AS-20250710144339
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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525
VISIT DATE: 07/17/2025
NARRATIVE
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Allegation: Staff mismanage resident's medication. It is alleged that on June 22, 2025 staff (S1) dropped R1's medications, but reported that the resident slapped the medications off of their hands. According to information obtained, S1 has recently been observed dropping medications during medication pass and when opening the medication bubble pack. Staff (S1) denied dropping medications on 6/22/2025, and stated that R1 was given the medication cup, and as the resident reached out to grab the medications they knocked the medications off onto the floor. Staff (S1) stated they picked up the medications and placed them in a bag to be destroyed, documented on the Medication Administration Record (MAR), and administered the same medications from a later date. A total of nine staff were interviewed. Staff interviews revealed that most of the medication pill drops are accidental due to resident's dexterity ability. During the course of the investigation, record review revealed that on 7/13/2025, resident (R2's) medications fell from the medication cup onto the floor because R2 placed the pills in to their mouth quickly. Staff administered medications from a later date, and medication replacement was ordered. A third medication incident was reported today. The incident report alleges that yesterday (7/16/25), R2's medication pill fell on the floor, and S2 picked up the medication and administered the contaminated pill. Therefore, there is sufficient evidence to corroborate the allegation.

Allegation: Staff do not keep the facility free of pests. The complaint alleges that the July 5, 2025, night shift staff failed to observe ants on resident (R2's) bed, body, and floor. According to information obtained, at approximately 6:20 AM, staff observed ants on R2's feet and arms, and when they checked the resident's room they saw ants all over the resident's bed, as well as an ant trail coming from the hallway. Staff interviews confirmed the incident. Administration staff stated the facility has ongoing pest control services in place, and places work orders if issues are observed. Staff stated they have observed ants in the kitchen area, hallways, and the isolated incident in R2's room. Administrator placed a pest control work order on 7/7/2025, and Dewey Pest Control personnel treated the facility on 7/11/2025. Picture evidence was obtained. It depicts ants all over R2's bed comforter, mattress pad, and along the wall baseboards. There is sufficient evidence to corroborate the allegation.

Based on document review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited according to California Code of Regulations, Title 22. Refer to LIC 9099D.

Exit interview was conducted with Administrator and a copy of appeal rights and report was issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250710144339
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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2025
Section Cited
CCR
80075(b)(5)(B)
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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.....Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met evidenced by:
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Administrator agreed to submit proof of staff in-service training.
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Based on record review, on 7/13/25 two of R2's medication pills fell on the floor, and on 7/16/25, staff (S2) administered to R2 one 1 that fell on the floor. This poses a potential health, safety, and personal rights risks to clients in care.
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Type B
07/28/2025
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met by evidence of:
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Administrator shall ensure the interior of the facility is free of insects and/or pests.

Submit proof of on-going pest control service contract and a picture that R2's window screen was repaired.
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Based on picture evidence and interviews, it was confirmed that on 7/6/2025 R2 had ants on their body, bed, and bedroom floor. This posed a potential health, safety, and personal rights risks to 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3