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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603531
Report Date: 08/25/2023
Date Signed: 08/25/2023 01:42:36 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
08/18/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230818162612
FACILITY NAME:FAIR OAKS MANORFACILITY NUMBER:
198603531
ADMINISTRATOR:ALMERO, CARMENFACILITY TYPE:
735
ADDRESS:1753 N. FAIR OAKS AVE.TELEPHONE:
(626) 345-9788
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:14CENSUS: 10DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carmen Almero, administratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has a bed bug infestation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met with Carmen Almero, administrator. LPA explained the purpose of today's visit regarding the above-mentioned allegation.

Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #3 (S3); attempted to interview clients from client#1 (C1) to client#4 (C4); reviewed pest control services document and toured the facility. LPA obtained copies of staff and client rosters; and facility file with relevant information.

The investigation revealed the following:
In regard to allegation of “facility has a bed bug infestation,” it is alleged that facility had bed bugs. LPA attempted to interview clients from C1 to C4 but all attempts failed.

(-continued in LIC 9099C-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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-20230818162612
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: FAIR OAKS MANOR
FACILITY NUMBER: 198603531
VISIT DATE: 08/25/2023
NARRATIVE
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Per staff interviews, all three (3) staff, including administrator, corroborated the allegation and stated facility had bed bug. During facility's tour today, 8/25/23, LPA Tao observed a dead bed bug on the floor near the bed in room#7. Documents review revealed pest control had identified bed bugs activity in room #7 and a pest control treatment had scheduled on 8/26/23 for bed bugs treatment.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview was conducted with Carmen, Administrator and a copy of this report, LIC 9099D, and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230818162612
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: FAIR OAKS MANOR
FACILITY NUMBER: 198603531
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
80087(a)(1)
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(a) 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.
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Licensee will maintain a contract with pest control company to address the bed bug problem, until the facility is free of bed bugs. Administrator will provide LPA with detailed monthly reports until the facility is free of bed bugs.
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This requirement has not been met as evidenced by:

Per staff interviews and physical plant, facility had a bed bug infestation.
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Administrator ensure to comply with all recommendations given by pest control company if that is needed. Due on POC due date.
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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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3