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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005407
Report Date: 11/17/2022
Date Signed: 11/17/2022 09:53:18 AM

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
10/03/2022 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221003162607
FACILITY NAME:MAISON FOR MOMFACILITY NUMBER:
306005407
ADMINISTRATOR:LUDINOT NIC, YAMASHIRO SHEFACILITY TYPE:
740
ADDRESS:804 W BRENTWOOD AVENUETELEPHONE:
(310) 994-9181
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 6DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Staff on duty-Arlene "Joyce" CorejoTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Resident sustained a black eye while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio was greeted and granted entry by staff on duty, who contacted facility administrator (AD) Shelly Yamashiro about visit. LPA De Perio stated the purpose of this visit which was to deliver the final findings for the complaint received on 10/3/22 against this facility. AD Yamashiro was unable to be present during time of visit, however, provided consent for staff on duty (S1) Arlene "Joyce" Corejo to receive and sign report.

For today's visit, there are a total of 6 residents in care of which 1 is on hospice, and a total of 2 staff members on duty. This agency has investigated the complaint alleging that resident sustained a black eye while in care. LPA De Perio conducted record reviews and interviews with residents, staff, and responsible party of resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
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-20221003162607
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: MAISON FOR MOM
FACILITY NUMBER: 306005407
VISIT DATE: 11/17/2022
NARRATIVE
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Upon conducting the investigation, it was stated that resident did sustain a black eye while in care, however, was due to an accident. There was no information that indicated that any physical abuse took place. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

LPA De Perio conducted an exit interview with S1 and AD Yamashiro via phone call and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2