306003954-3-29-2021-22-AS-LADS-BZVUNA-20210408154334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003954
Report Date: 03/29/2021
Date Signed: 03/29/2021 10:35:18 AM

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
06/15/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200615120251

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: 3	DATE:	03/29/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Normita Vibar - Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide lunch for resident
Facility does not provide water when requested
Facility does not provide adequate quality or quantity of food
Facility staff yells at resident
Facility does not maintain room. Resident has no light source and needs a new mattress
Facility staff denies resident speaking to certain people

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Patricia Velazquez contacted the facility via telephone to conduct a subsequent complaint investigation visit telephonically due to the COVID-19 Pandemic and pre-cautionary measures. LPA Velazquez initially spoke with Administrator Normita Vibar and then conducted interviews.

On today's visit LPA Velazquez requested copies of facility and resident records. LPA also conducted interviews with Resident (R) #1 and staff. During the course of the investigation the following was revealed: LPA Velazquez conducted a tour of the physical plant utilizing FaceTime virtual technology and observed sufficient furnishings in R's room. LPA reviewed copies of menus as served for R1 and these menus showed a variety of foods served at each meal. R1 indicated they are offered snacks but does not always eat snacks because R1 chooses not to eat the snacks provided. R1 indicated the facility provides plenty of water and tea to drink throughout the day. LPA Velazquez conducted interviews with R1 and staff who provided conflicting

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

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-20200615120251

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: 03/29/2021

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

statements and were not able to corroborate the allegations. The records reviewed also indicated a variety of meals are being served to all residents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegations: Facility does not provide lunch for resident, Facility does not provide water when requested, Facility does not provide adequate quality or quantity of food, Facility staff yells at resident, Facility does not maintain room, Resident has no light source and needs a new mattress, and Facility staff denies resident speaking to certain people are all deemed unsubstantiated.

An exit phone interview was conducted with Administrator Normita Vibar and a copy of this report was signed by LPA Patricia Velazquez. This report along with the LIC 811s will be sent via email to Administrator Vibar who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Administrator Normita Vibar agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange. LPA Velazquez provided the RO address to Administrator Normita Vibar.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2