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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004477
Report Date: 03/01/2023
Date Signed: 03/01/2023 12:21:55 PM

Unsubstantiated


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
09/08/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220908141420
FACILITY NAME:ROSIE HALL FAMILY HOMEFACILITY NUMBER:
306004477
ADMINISTRATOR:KARRY VALLEJOFACILITY TYPE:
735
ADDRESS:2031 S. ARTESIA STREETTELEPHONE:
(714) 831-1336
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:4CENSUS: 4DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karry Vallejo - AdministratorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility is out of ratio
Facility does not have enough food for clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez along with Regional Center Orange County (RCOC) Quality Assurance Coordinator (QAC) Jacqueline Puente conducted an unannounced subsequent complaint visit to deliver the findings of the investigation regarding the above allegations.

On today’s visit LPA Velazquez and QAC Puente conducted an interview with Staff (S) #1. LPA Velazquez also reviewed and obtained copies of facility, client, and staff records. Regarding the allegation: Facility is out of Ratio the investigation revealed the following. LPA Sean Haddad conducted the initial complaint visit on September 14, 2022 and conducted an interview with S1. LPA Haddad also obtained copies of pertinent records. The records reviewed included Client Physician's Reports, Individual Program Plans (IPPs), staff time sheets for September 4, 2022 - October 1, 2022 and staff work schedules. Per S1 the work shifts are 6 - 9 AM, 2 PM - 10 PM and the NOC shift from 10 PM - 9 AM the next day. For Saturdays and Sundays there are 2 shifts, 8 AM - 8 PM and 8 PM - 8 AM the next day. Per S1 the first 2 shifts each day have 2 staff present for the
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 5
Control Number 22-AS-20220908141420
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: ROSIE HALL FAMILY HOME
FACILITY NUMBER: 306004477
VISIT DATE: 03/01/2023
NARRATIVE
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4 clients in care and 1 staff for the NOC shift. Based on the observations of LPAs Sean Haddad and Patricia Velazquez and QAC Jacqueline Puente, interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility is out of ratio is deemed UNSUBSTANTIATED.

Regarding the allegation: Facility does not have enough food for clients during the course of the investigation the following was revealed: LPA Sean Haddad conducted the initial complaint visit on September 14, 2022 and observed an adequate supply of perishable and non-perishable food present in the facility that was documented with photographs. Records reviewed included the facility’s Grocery Funds Ledgers documenting food purchases, Meal Planner Menus from July 2022 – March 2023, CalFresh EBT Cards for Client (C) #1 and C2, C1’s CA.Gov Transaction History for dated June 17, 2022 – September 14, 2022 and December 7, 2022 - March 7, 2023, C2’s CA.Gov Transaction History dated June 17, 2022 – August 24, 2022 and December 8, 2022 - March 8, 2023. On today’s date LPA Velazquez and QAC Jacqueline Puente observed the facility had an adequate supply of perishable and non-perishable food present in the facility as well as an emergency food supply. Based on the observations of LPAs Sean Haddad and Patricia Velazquez and QAC Jacqueline Puente, interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility does not have enough food for clients is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Karry Vallejo and a copy of this report along with the appeal rights, LIC 811s, and LIC 9098 were provided at the time of this visit.


SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/08/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220908141420

FACILITY NAME:ROSIE HALL FAMILY HOMEFACILITY NUMBER:
306004477
ADMINISTRATOR:KARRY VALLEJOFACILITY TYPE:
735
ADDRESS:2031 S. ARTESIA STREETTELEPHONE:
(714) 831-1336
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:4CENSUS: 4DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karry Vallejo - AdministratorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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9
Administrator is using clients EBT cards for other facilities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez along with Regional Center Orange County (RCOC) Quality Assurance Coordinator (QAC) Jacqueline Puente conducted an unannounced subsequent complaint visit to deliver the findings of the investigation regarding the above allegation.

Regarding the allegation: Administrator is using clients EBT cards for other facilities during the course of the investigation the following was revealed: LPA Sean Haddad conducted the initial complaint visit on September 14, 2022 and conducted an interview with S1. During the investigation at Billy’s House #306005923 with Complaint Control Number: 22-AS-20220908144115, S1 provided conflicting statements regarding how the CalFresh EBT benefits were being utilized by Billy’s House and this facility. S1 confirmed the groceries purchased by a client’s EBT card at Billy’s House were being shared with other clients in care. S1 further confirmed the groceries purchased by C1 and C2’s EBT cards were shared with the other clients in this home which is a violation of the use of the CalFresh EBT card benefits. Records reviewed included Client Individual
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220908141420
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: ROSIE HALL FAMILY HOME
FACILITY NUMBER: 306004477
VISIT DATE: 03/01/2023
NARRATIVE
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Program Plans, Physician’s Reports, CalFresh EBT Cards for Client (C) #1 and C2, C1’s CA.Gov Transaction History for dated June 17, 2022 – September 14, 2022 and December 7, 2022 - March 7, 2023, C2’s CA.Gov Transaction History dated June 17, 2022 – August 24, 2022 and December 8, 2022 - March 8, 2023, the facility’s Grocery Funds Ledgers and Meal Planner Menus from July 2022 – March 2023. Based on LPA's observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Administrator is using clients EBT cards for other facilities is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099D.



An exit interview was conducted with Administrator Karry Vallejo and a copy of this report along with the appeal rights, LIC 811s, and LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20220908141420
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: ROSIE HALL FAMILY HOME
FACILITY NUMBER: 306004477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2023
Section Cited
CCR
80012(a)
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False Claims. No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: based on record
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The Licensee to submit a written statement to LPA indicating how they intend to adhere to 80012(a) regulation by POC due date.
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review and interview the licensee failed to provide accurate statements regarding the utilization of the clients’ EBT cards. This poses an immediate risk to the health and safety of 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5