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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005504
Report Date: 11/06/2023
Date Signed: 11/06/2023 04:41:31 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
12/04/2020 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201204144148
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: 4DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Rey Dagatan, Caregiver and Cresencia Santiago, Administrator (Via telephone)TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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-There is lack of food in facility
-Facility not following the menu
INVESTIGATION FINDINGS:
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 On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to the facility to follow up on allegations listed above. LPA Quiroz was greeted and granted entry by Caregiver Ray Dagatan. Licensee/Administrator (L/AD)Cresencia Santiago arrived during today's visit. LPA Quiroz discussed purpose of today's visit upon (L/AD) Santiago's arrival.
The 10 day visit was conducted by LPA Shobhana Frank on 12/14/2020 virtually due to COVID-19 Pandemic.
During the course of this investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, clients, witnesses and reviewed documentation but not limited to facility menu, staff roster, client roster, Physician Reports, Identification Forms and Individual Program Plans.
It is alleged that “there is lack of food in facility” and “Facility not following the menu.” During today's inspection visit, on or about 10:48am while conducting inspection tour of the kitchen area along with Caregiver Dagatan and (L/AD) Santiago, LPA Quiroz observed two dozen of eggs with expiration date of November 2022, CONTINUED ON NEXT LIC 9099-C PAGE...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
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 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
12/04/2020 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201204144148

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: DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Rey Dagatan, Caregiver and Cresencia Santiago, Administrator (Via telephone)TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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-Facility refuses to cook on weekends
-Facility has insufficient staff
INVESTIGATION FINDINGS:
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 On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to the facility to follow up on allegations listed above. LPA Quiroz was greeted and granted entry by Caregiver Ray Dagatan. Licensee/Administrator (L/AD)Cresencia Santiago arrived during today's visit and discussed purpose of today's visit.
The 10 day visit was conducted by LPA Shobhana Frank on 12/14/2020 virtually due to COVID-19 Pandemic.
During the course of this investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, clients, witnesses and reviewed documentation but not limited to facility menu, Personnel Report LIC 500, client roster, Physician Reports, Identification Forms and Individual Program Plans.
It is alleged that “Facility refuses to cook on weekends" and that "Facility has insufficient staff."
Regarding the allegation, "Facility refuses to cook on weekends," the investigation revealed the following: Four of four interviewees indicated facility staff cook on the weekends. CONTINUED ON NEXT LIC 9099-C PAGE...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20201204144148
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: 11/06/2023
NARRATIVE
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CONTINUED...Two of four interviewees indicated "staff cook on the weekends, it may not be the food the clients like but they cook."
Regarding the allegation, "Facility has insufficient staff" the investigation revealed the following: Facility is a level 3 home. (L/AD) Crescencia Santiago indicated "two clients are in day program from 8:00am-2:30pm and the other two work and go to school so they get back later in the evening." Two of four interviewees indicated "The staffing was not good during COVID, some staff moved back to the philipines and there's new staff now."
LPA Quiroz reviewed LIC 500-Personnel list during today's visit which indicates there is one caregiver on day shift hours seven days per week, and (L/AD) Santiago indicated living at the facility.
The department has investigated the allegations listed above.

Therefore based on the preponderance of evidence gathered through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegation that the "Facility refuses to cook on weekends" and "Facility has insufficient staff" was found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with (L/AD) Cresencia Santiago, and a copy of this report, along with LIC9099-D, Appeal Rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20201204144148
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: 11/06/2023
NARRATIVE
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CONTINUED...two (16 oz) containers of turkey bologna with expiration date of 11/5/2023, Sarsa NG Lechon all purpose sauce with expiration date of 12/2020, Cranberry juice with expiration date of 9/27/2023, baked organic apple chips with expiration date of 1/18/2022, hot dog bread with expiration date 11/2/2023, two packs of hamburger bread with expiration date of 10/31/2023, cactus honey powder with expiration date of January 2021, orange color unknown fruit in zip lock bag dated 7/7/2023 with foul odor detected, 2 containers of ranch dressing with expiration date of 10/18/2023 and crispy onions salad gourmet toppings with expiration date of 10/7/2023. All expired items listed above were verified with Caregiver Datanga and (L/AD) Cresencia Santiago during today's visit. (L/AD) Santiago indicated "Oh it's my food, but i'll throw it away because today is grocery day." LPA Quiroz provided consultation on California Code of Regulation (CCR) 85076 Food Service(d)(1).(L/AD) Santiago indicated understanding.
On or about 11:45am, LPA Quiroz reviewed facility food menu posted on refrigerator. LPA Quiroz reviewed Tuesday lunch section indicating lunch options to be hot dog with relish, burrito, meat loaf sandwich or bologna sandwich. Four of four items listed for Tuesday lunch, were observed to not be readily available during today's visit as a result of two of four items observed to be thrown away during today's visit due to expiration dates.
During today's visit, while inspecting kitchen area, LPA Quiroz did not observe supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days, as evidenced by multiple expired food items observed during today's visit.
Based on the preponderance of evidence gathered through multiple interviews, observations and documents obtained; the allegations “There is lack of food in facility,” and “Facility not following the menu” has been met; Therefore, the allegations listed above are deemed to be SUBSTANTIATED.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations. (SEE LIC 9099-D)

An exit interview was conducted with (L/AD) Cresencia Santiago, and a copy of this report, along with LIC9099-D, Appeal Rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20201204144148
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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2023
Section Cited
CCR
85076(d)(1)
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85076 Food Service(d)The licensee shall meet the following food supply and storage requirements:(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. CONTINUED BELOW
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On today's date, L/AD Santiago purchased groceries for facility today. Proof of purchased was provided to LPA Quiroz.
L/AD indicated understanding CCR 85076(d)(1) indicating she would provide and submit inservice training for staff and submit to CCL by 11/10/2023.
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This requirement was not met as evidenced by:on or about 10:48am while conducting inspection tour of the kitchen area along with Caregiver Dagatan and (L/AD) Santiago, LPA Quiroz observed multiples food items listed on LIC 9099 and LIC 9099-C page
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were observed to be epired. All expired food items were verified with Caregiver Datanga and (L/AD) Cresencia Santiago during today's visit. (L/AD) Santiago indicated "Oh it's my food, but I'll throw it away, because today is grocery day."
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5