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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003751
Report Date: 06/19/2025
Date Signed: 06/19/2025 12:13:04 PM

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
06/18/2025 and conducted by Evaluator Erik Zaragoza
COMPLAINT CONTROL NUMBER: 28-AS-20250618113315
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: 4DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Herminia Baldevia - CaregiverTIME COMPLETED:
12:26 PM
ALLEGATION(S):
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Licensee did not ensure that staff dispensed medications to clients as prescribed
Licensee did not ensure that all direct services to clients requiring specialized skills are performed by personnel who are qualified
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with Herminia Baldevia, caregiver for the facility, and explained the purpose of the visit. Administrator Martha Losoya arrived shortly thereafter.

The investigation consisted of the following: LPA interviewed Clients #1 - 4 (C1 - C4), Staff #1 - 4 (S1 - S4), reviewed the medications along with the Medication Administration Records (MARs) for C1 - C4, reviewed the staff files for S1 - S4 along with the file of Staff #5 (S5), and also reviewed a Corrective Action Plan (CAP) from the East Los Angeles Regional Center (ELARC) dated 6/17/2025.

The investigation revealed the following: In regards to the allegation that "Licensee did not ensure that staff dispensed medications to clients as prescribed," it is alleged that one of the staff that C4 was administered a medication in a manner that did not adhere to the doctor's order, and a pro re nata (PRN) medication for C3 had been expired.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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-20250618113315
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: 06/19/2025
NARRATIVE
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During interviews with the clients, none of them corroborated the allegation. One of the clients interviewed stated that they have been getting all the medications that they require and that they have no issues with obtaining them. Another client interviewed stated that everything is okay with their medications. During interviews with the staff, four (4) out of four (4) corroborated the allegation. One staff interviewed stated that they were aware that there were errors in distributing the medications to C4. Another staff interviewed also stated that they were aware of the medication error and that the PRN medication for C3 had expired, and that they had ordered a refill of a medication. During review of the medications and MARs for the clients, LPA observed that C4 was given a medication which according to the doctor's order should only be given when their blood pressure is higher than 140/90, however on on 6/4/2025 it was given when their reading was 139/86. LPA also observed C3's PRN medication will need to be ordered, and observed evidence from staff that it has been.

In regards to the allegation "Licensee did not ensure that all direct services to clients requiring specialized skills are performed by personnel who are qualified," it is alleged that some of the staff in the facility did not complete required training to be qualified to provide direct services to clients including Direct Support Staff 2 (DSP2) training. During interviews with clients, none of them corroborated the allegation. All of the clients interviewed stated that the staff are all helpful and assist them with all their needs. During interviews with the staff, four (4) out of four (4) corroborated the allegation. S3 stated that she had been working at the facility for three (3) years, however she needs to obtain her DSP2 training certificate which is required after working as a DSP after working at a facility for two (2) years. Another staff interviewed stated that they were aware that S3 required their DSP2 training, and possibly S5 as well. During record review of the staff, LPA determined that S3 will need their DSP2 training, and S5 as well because their DSP2 training was not found in their file.

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 and Chapter 6 is being cited on the attached LIC9099D pages.

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

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250618113315
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: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2025
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This regulation is not met as evidenced by:
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**POC Cleared** Administrator is to ensure that medications are properly distributed to clients at all times. Administrator is to have an in-service training amongst staff on medication administration and email it to the LPA by the POC due date.
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Based on interview and record review, it was determined that a medication error was made when distributing medicatinos to C4, and that C3's medication had expired, which poses an immediate health and safety risk to clients in care.
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Type B
07/17/2025
Section Cited
CCR
85065(f)
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(f) The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service.

This regulation is not met as evidenced by:
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Administrator is to ensure that all staff have their appropriate DSP training certificates in their files at all times. Administrator is to obtain the DSP2 training certificates for S3 and S5 and email them to LPA by the POC due date.
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Based on interview and record review, LPA determined that 2 of the staff who have worked at the facility for over 2 years did not have their DSP2 training certificates, 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: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3