198603585-5-17-2023-28-AS-LHIS-CS3K5U-20230522073627

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603585
Report Date: 05/17/2023
Date Signed: 05/17/2023 09:21:13 AM

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
12/12/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221212100233

FACILITY NAME:	HENRIETTA'S HOME		FACILITY NUMBER:	198603585
ADMINISTRATOR:	AQUINO, ROBIN		FACILITY TYPE:	740
ADDRESS:	131 SEGOVIA AVENUE		TELEPHONE:	(626) 703-4958
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS: 4	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Belent Taico, Manager		TIME COMPLETED:	09:25 AM

ALLEGATION(S):

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Licensee misrepresented to the Department that they have liability insurance.

INVESTIGATION FINDINGS:

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This unannounced subsequent complaint inspection is being conducted by Licensing Program Analyst (LPA) Galarza for the purpose of delivering findings for the investigation into the above identified complaint allegation. The LPA met with Manager Belen Taico and explained the reason for today’s inspection. There was concern that the Licensee representative misrepresented to the Department that they had liability insurance.

On 12/13/2022, LPA Galarza conducted the initial 10-day complaint investigation and conducted interviews from 8:05 a.m. to 3:45 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Interviews conducted with facility staff and witnesses revealed that facility was actively working with multiple insurance agencies to finalize the policy to comply with Title 22 Regulations. Based on review of the policies submitted to the Department between 08/26/2022 and 12/06/2022 there is insufficient information to support the allegation.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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