306003954-6-17-2020-22-AS-LADS-BQQTFP-20200619144152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003954
Report Date: 06/17/2020
Date Signed: 06/17/2020 01:15:06 PM

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
05/29/2020 and conducted by Evaluator Miguel Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200529111009

FACILITY NAME:	PILGRIMS GUEST HOME		FACILITY NUMBER:	306003954
ADMINISTRATOR:	NORMITA/JOSE VIBAR		FACILITY TYPE:	740
ADDRESS:	8431 SANTA BERTA WAY		TELEPHONE:	(714) 995-4020
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 4	DATE:	06/17/2020
		UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	Administrator: Normita Vibar		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Administrator has client cleaning personal home

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Due to COVID-19 and pre-cautionary measures that Community Care Licensing Division (CCLD) is taking, on 06.17.20, Licensing Program Analyst, (LPA) Miguel Garcia contacted administrator Normita Vibar via telephone to discuss and deliver the final findings for this complaint.

The Department received a report alleging that the administrator has client cleaning her personal home. During the investigation and on 06.03.20, Licensing Program Analyst (LPA) Miguel Garcia conducted the 10 days visit via telephone. LPA Garcia did not interview the client because the client doesn’t speak English and is almost non-verbal. LPA Garcia talked with the facility administrator. The administrator denied the allegation. LPA Garcia contacted Regional Center of Orange County. LPA Garcia obtained statements. The statements did not corroborate the allegation. LPA Garcia called and talked with the family. LPA Garcia obtained statements. The statements did not corroborate the allegation.

*** report continues in the next page ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Miguel Garcia	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020

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 2

Control Number 22-AS-20200529111009

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: PILGRIMS GUEST HOME	FACILITY NUMBER: 306003954
	VISIT DATE: 06/17/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Therefore, based on the statements obtained from facility staff, family, and Regional Center of Orange County, the allegation: administrator has client cleaning personal home, is unsubstantiated and although the allegation may have happened, there is not a preponderance of evidence to prove that the alleged violation occurred.

However, it is noted that from now on, the family requested that the client does not leave the facility unless it is for medical appointments or to attend day program. The family is concerned because the resident has asthma and can’t be exposed to COVID-19. For this reason, LPA Garcia called and informed the administrator and Regional Center about the family wishes. The administrator stated that she will comply with the family’s wishes.

An exit interview was conducted via telephone with administrator Normita Vibar. This report was sent via email and an electronic email read receipt confirms receiving of the report. Mrs. Vibar agrees to sign the report and fax it to LPA Garcia.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Miguel Garcia	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2