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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004596
Report Date: 04/18/2023
Date Signed: 04/18/2023 06:29:35 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
04/10/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230410165541
FACILITY NAME:JON ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004596
ADMINISTRATOR:LEONCIO CANLASFACILITY TYPE:
735
ADDRESS:3801 LARIAT PLACETELEPHONE:
(714) 770-0892
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 3DATE:
04/18/2023
UNANNOUNCEDTIME BEGAN:
04:31 PM
MET WITH:Leoncio CanlasTIME COMPLETED:
06:46 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are falsifying personnel records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA was greeted and granted entry by staff. LPA met with Administrator Leoncio Canlas and explained the reason for the visit. LPA toured the facility and interviewed staff. It was alleged the facility staff training certificates are not valid. LPA reviewed 4 staff files including training documents. LPA observed Staff 1(S1), Staff 2 (S2) and Staff 3 (S3) all have Crisis Prevention Institute, Inc. (CPI) training certificates for Nonviolent Crisis Intervention for 12 hours conducted by Trainer 1 (T1) and Trainer 2 (T2). S1 and S2 have training by T1 and S3 by T2. T1 and T2 are not recognized by CPI and they have no record of either Trainer (See complaint # 22-AS-20230313134603). The in-authentication of the certificate voids the 12 training hours for S1, S2 and S3. LPA observed that 4 out of the 4 staff files reviewed had no current/valid First-Aid/CPR training. S1, S2 and S3 are direct care staff. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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 2
Control Number 22-AS-20230410165541
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: JON ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004596
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2023
Section Cited
HSC
1550(c)
1
2
3
4
5
6
7
The department may.. or suspend or revoke) any license of subdivision (b) of Section 1524 for any of the following grounds:
(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement is not being met:
1
2
3
4
5
6
7
Licensee to forward a statement of understanding of the regulation to LPA by POC due date.
8
9
10
11
12
13
14
Based on observation and interview, Licensee failed to ensure moral conduct in facility dealings. Facility provided false training documents to LPA. CPI training records are not recognized by CPI. This poses an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
04/28/2023
Section Cited
CCR
80065(f)
1
2
3
4
5
6
7
All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not being met as evidenced by:
1
2
3
4
5
6
7
Licensee to provide verifiable training to staff and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on observation and interview, Licensee failed to ensure staff are trained. Three out of four staff have false training records. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
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: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2