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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003751
Report Date: 03/11/2025
Date Signed: 03/11/2025 11:08:12 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/06/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250306095524
FACILITY NAME:CRJ HOMEFACILITY NUMBER:
306003751
ADMINISTRATOR:CRISTINA SANTOSFACILITY TYPE:
735
ADDRESS:15044 BARNWALL STREETTELEPHONE:
(714) 521-5956
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 5DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Herminia Baldevia - CaregiverTIME COMPLETED:
11:23 AM
ALLEGATION(S):
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Facility is not keeping accurate records of client medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced complaint visit to investigate the allegation listed above. LPA met with Herminia Baldevia, direct support staff (DSP) for the facility, and explained the purpose of the visit. House supervisor Loida Samonte arrived shortly thereafter.

The investigation consisted of the following: LPA Erik Zaragoza obtained the staff records, client records, reviewed the medications along with the Medication Administration Records (MARs) for Clients #1 - 5 (C1 - C5), reviewed a Corrective Action Plan (CAP) from the East Los Angeles Regional Center (ELARC) dated 3/5/2025, and interviewed Staff #1 - 3 (S1 - S3), along with C1 - C4. LPA attempted to interview C5 however they were attending school at the time of the visit.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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-20250306095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRJ HOME
FACILITY NUMBER: 306003751
VISIT DATE: 03/11/2025
NARRATIVE
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The investigation revealed the following: In regards to the allegation that "Facility is not keeping accurate records of client medication," it is alleged in the CAP issued by ELARC that the MARs for C1 was not initialed by staff members on the dates 2/1/2025 - 2/19/2025. During interviews with the clients, none of them corroborated the allegation. All clients interviewed stated that staff have been assisting them with obtaining their medications and that there have been no issues in regards to this. During interviews with the staff, three (3) out of three (3) corroborated the allegation. One of the staff members interviewed confirmed that the MARs was not initialed for the time frame described in the CAP, and stated it was likely due to the staff mistaking that the medication had already been initialed because its name is very similar to another medication that C1 takes. Another staff interview stated that they were aware that there was an error made in not initialling the MARs correctly for C1. During review of C1's MARs for the month of February 2025, LPA confirmed that the medication had not been initialed on the MARs between the dates of 2/1/2025 - 2/19/2025. During review of the MARs for the month of March of 2025, LPA observed that all medications had been administered and initialled in the MARs correctly.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 is being cited on the attached LIC9099D.

Exit interview was held and a copy of the report along with the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250306095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRJ HOME
FACILITY NUMBER: 306003751
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2025
Section Cited
CCR
80070(a)
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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This regulation is not met as evidenced by:
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Licensee is to ensure that client records and MARs are completed fully and kept current at all times. Administrator is to provide in-service training to all staff on appropriate medication dispensing procedures and email the materials and list of attendees to LPA by the POC due date.
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Based on interview and record review, the facility did not accurately and completely initial the MARs for C1 after administering their medications, which poses a potential health and safety risk 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3