<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004293
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:22:42 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
03/29/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230329165330
FACILITY NAME:STEVENS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004293
ADMINISTRATOR:ROMMEL MENDOZAFACILITY TYPE:
735
ADDRESS:106 W. STEVENS AVENUETELEPHONE:
(714) 662-5717
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY:6CENSUS: 3DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff on duty-Alfonso PoquizTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not providing activities for clients.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Celine De Perio made an unannounced complaint visit to the facility to initiate the 10-day visit for the complaint received on 3/29/23 and to deliver the findings. LPA was greeted by staff on duty (S1) who contacted office manager (OM) Lora Aquino and temporary facility administrator (AD) John Castro about visit. OM and AD were unable to be present during time of visit, but provided consent for S1 to recieve and sign report.

For today's visit, there are a total of 3 clients in care of which 1 was not present due to attending Day Program. LPA conducted a tour of the interior portion of the facility with S1. During this visit, LPA conducted record reviews, interviews and obtained copies of pertinent documents.

SEE LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
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 22-AS-20230329165330
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: STEVENS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004293
VISIT DATE: 04/06/2023
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
This department has investigated the complaint alleging that facility is not providing activities for clients.

LPA conducted a total of 6 interviews which consisted of staff and clients. 2 of the interviews conducted stated that the facility does facilitate activities for the clients, however 3 of the interviews corroborated with the allegation stating that aside from attending Day Program, the facility does not provide activities for clients in care.

LPA reviewed documents such as but not limited to: all client physician reports, staff schedule, staff roster, client roster, activity schedule and Day Program tracking log.

LPA observed that the facility has a weekly activity schedule with varying activities such as: walking, movie nights, yoga, indoor games, arts and crafts and video games. LPA inquired as to where the supplies for the following activities were located, to which 3 out of the 6 interviews reported that there were no supplies in relation to the listed activities. During the tour of the interior and exterior portion of the facility, LPA observed that there were no activity supplies available to clients in care.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

For today's visit, a citation was issued per Title 22 California Code of Regulations.

An exit interview was conducted with S1, a copy of this report and Appeal Rights were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230329165330
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: STEVENS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004293
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
85079(a)(1-2)
1
2
3
4
5
6
7
85079 Activities
(a) The licensee shall ensure that planned recreational activities...are provided for the clients:
(1) Activities that require group interaction.
(2) Physical activities...
This requirement is not met as evidence by:
1
2
3
4
5
6
7
As plan of correction (POC), the facility will review the regulation cited, and will create and follow the activity schedule posted. Facility will also obtain the proper supplies to support the activities listed.
8
9
10
11
12
13
14
Based on LPAs observations, interviews conducted and record review, licensee failed to ensure that planned recreational activities...are provided for the clients...
This can pose a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Facility will submit proof of the understanding to the regulation section cited to community care licensing (CCL) and the assigned LPA on or by 4/14/23.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3