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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005504
Report Date: 10/11/2022
Date Signed: 10/20/2022 09:45:18 AM

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
07/14/2022 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220714110042
FACILITY NAME:OUR LADY OF GUADALUPE HOMEFACILITY NUMBER:
306005504
ADMINISTRATOR:CRESENCIA D. SANTIAGOFACILITY TYPE:
735
ADDRESS:24361 BRIDGER RDTELEPHONE:
(949) 328-9784
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 3DATE:
10/11/2022
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Facility Administrator - Cresencia "Christine" SantiagoTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Client was given an unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Administrator (AD) Cresencia "Christine" Santiago and stated the purpose of this visit which was to deliver the final findings for the complaint received on 7/14/22 against this facility.

For today's visit, there are a total of 3 clients in care.

This agency has investigated the complaint alleging that client was given an unlawful eviction. LPA De Perio reviewed facility documentation and interviewed staff and clients. Specifically, the interview conducted with the client who received a 30-day notice from the AD, stated that although notice was signed and acknowledged, client had plans of wanting to move out anyways. However, per interview with AD, the reason for 30-day notice was due to client not being present in facility and residing in family’s house for more than 2 weeks.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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 3
Control Number 22-AS-20220714110042
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: OUR LADY OF GUADALUPE HOME
FACILITY NUMBER: 306005504
VISIT DATE: 10/11/2022
NARRATIVE
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 Per Title 22, Division 6 of the California Code of Regulations section 85068.5 Eviction Procedures, this incident does not fall under the criteria for a 30-day notice for eviction.

NOTE: Community Care Licensing Regional Office was not notified about client's 30-day notice.

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

For today's visit citations were issued per Title 22 Division 6 of the California Code of Regulations.
See LIC9099-D.

LPA De Perio conducted an exit interview with AD Santiago a copy of this report, regulations discussed and specified on LIC9099-D and Appeal Rights were provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220714110042
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: OUR LADY OF GUADALUPE HOME
FACILITY NUMBER: 306005504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
85068.5(a)(1-5)
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85068.5 Eviction Procedures
(a) The licensee... permitted to evict a client...with a 30-day written notice...for any of the following:...
This requirement is not met as evidence by:
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As a plan of corection (POC), facility will ensure that if a client is given a 30-day notice, it will meet criteria as specified in 85068.5(a)(1-5). Facility will submit written proof to CCL and the assiged LPA adhereing to this POC and understanding of the regulation discussed on or by 10/25/2022.
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Based on observation, and interviews, facility provided client with a 30-day notice, however did not meet regulations as specified in 85068.5(a)(1-5). This poses a potential threat on safety of clients in care.
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CCR
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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: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3