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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002025
Report Date: 11/02/2022
Date Signed: 11/02/2022 04:18:58 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221028131728
FACILITY NAME:LONIKA HOME IIFACILITY NUMBER:
306002025
ADMINISTRATOR:DEL ROSARIO, ELEANORFACILITY TYPE:
735
ADDRESS:24922 MOSQUERO ST.TELEPHONE:
(949) 305-0087
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
11/02/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Gloria Bayle, caregiver
Lori Cook, Administrator		TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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1/ Facility did not ensure that a separate, complete, and current record is maintained in the facility for each client.
2/ Facility refrigerator is not clean and in good repair.

4/ Facility has expired food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required complaint investigation into the allegations listed above. LPA arrived at facility, was greeted and granted entry by Gloria Bayle, caregiver after explaining the purpose of the visit. Administrator Lori Cook was notified of the visit by telephone and arrived later to assist with the visit. LPA additionally detailed the allegations being investigated at this time.

LPA requested and obtained the facility census, client records for all four individuals in caras well as the staff roster. At the time of the visit, all four clients are away at their respective day program. Clients returned from program during the visit and interacted with LPA upon their return. Clients are noted to be in good spirits, well kept and taken care of. All staff present are found to be background cleared at the time of the visit. All staff members are correctly associated with the facility in Guardian.

CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
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 6
Control Number 22-AS-20221028131728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LONIKA HOME II
FACILITY NUMBER: 306002025
VISIT DATE: 11/02/2022
NARRATIVE
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LPA conducted a review of clients records for clients C1, C2, C3 and C4. All files are found to include all necessary components requirements defined by the California Code of Regulations Section 80070 regarding Client Records. Slight discrepancies are observed for the records pertaining to clients C1 and C2. For both of these clients, the primary care physician information on file is shown to be out of date compared to the most recent physician examination performed. It is noted however that the facesheet included in the records has in both instances the correct information. Licensee was provided consultation during the visit and instructed to avoid conflicting information to be stored in the records. Additionally, current Individual Program Plans are not present in the clients records despite one-on-one meetings having been conducted earlier. On the allegation that facility did not ensure that a separate, complete, and current record is maintained in the facility for each client, based on the review of the files and interview of the administrator, it was determined that the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

LPA requested to observe the contents of the facility's refrigerator. LPA was able to observe and document in photographs that the bottom shelf is currently held with duct tape. The top of the fridge is also observed to be dusty and covered with cobwebs that facility staff dusted and removed during the visit after LPA photographed them. On the allegation that facility refrigerator is not clean and in good repair, per observations made by LPA, it was determined that the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

LPA reviewed the expiration dates on the perishable items stored in the facility's refrigerator. Multiple food items were observed and photographed by LPA. LPA was able to observe a clamshell box of salad that no longer was safe to consume as well as a bottle of sauce with a Best By date of August 2022. LPA pointed out the expired items to facility staff who disposed of them during the visit. On the allegation that facility has expired food, per observations made by LPA, it was determined that the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

On the basis of the documents review, interviews and observations conducted during the visit, deficiencies have been cited under California Code of Regulations, Title 22, Division 6. A exit interview was conducted with the facility representative over the phone and a copy of the report along with appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20221028131728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LONIKA HOME II
FACILITY NUMBER: 306002025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2022
Section Cited
CCR
80070(a)
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According to the California Code of Regulations Section 80070(a): "The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client."
This requirement is not being met as evidenced by records review and interview.
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Licensee is to update the yearly assessments and Individual Program Plans for each one of the clients before the Plan of Corrections due date.
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This poses a potential risk to the health & safety of clients in care.
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Type B
11/16/2022
Section Cited
CCR
80087(a)
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California Code of Regulations Title 22 Section 80087(a) indicates that "The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients (...)".

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Licensee will ensure that the broken shelf in the facility refrigerator gets repaired or replaced before the Plan of Corrections due date. Additionally, the top of the fridge will be maintained to be clean, sanitary and free of clutte and dust.
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This requirement is not being met as evidenced by observations conducted. This poses a potential risk to the health & safety of 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20221028131728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LONIKA HOME II
FACILITY NUMBER: 306002025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2022
Section Cited
CCR
80076(a)(1)
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The California Code of Regulations Title 22 Section 80076(a)(1) indicates that: "(1) All food shall be safe(...)"
This requirement is not met as evidenced by observations conducted during the visit. This poses a potential risk to the health of clients in care.
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Licensee will ensure the prompt removal of all expired and spoiled food items from the facility's refrigerator before the Plan Of Corrections 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6