306005508-11-15-2022-22-AS-LADS-CMTQ8E-20230106105637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005508
Report Date: 11/15/2022
Date Signed: 11/15/2022 01:50:25 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
11/09/2022 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221109102211

FACILITY NAME:	LOMITA GUEST HOME		FACILITY NUMBER:	306005508
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	1919 E LOMITA AVE		TELEPHONE:	(714) 602-6414
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 3	DATE:	11/15/2022
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Brevet Dao		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Dry food on the walls and the ceiling fan is dusty.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannouced visit regarding the complaint allegation listed above. LPA Haley was greeted and granted entry by staff. LPA Haley met with Administrator (AD) Brevet Dao and explained the reason for the visit.

LPA Haley interviewed AD Dao, Staff 1 (S1), Staff 2 (S2), Resident 2 (R2), Resident 3 (R3), and attempted to interview Resident 1 (R1) regarding the complaint allegation. AD Dao, emailed LPA Haley copies of the Physicans report, Appraisal Needs & Service Plan, Pre-placement appraisal, and emergency contact information for R1, R2, and R3.

Regarding the allegation above, the investigation revealed the following: During a walk through of the facility with AD Brevet, LPA Haley observed dust on celing fans in every resident bedroom and AD Brevet acknowledged the presence of the dust on the ceiling fans. LPA Haley took photos of the dusty ceiling fans before AD Brevet cleaned them up.
Continued on LIC9099 C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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-20221109102211

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: LOMITA GUEST HOME	FACILITY NUMBER: 306005508
	VISIT DATE: 11/15/2022

NARRATIVE

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Furthermore, during the walk through of the facility with AD Brevet, LPA Haley noticed broken blinds in the dining room window, broken blinds and a dirty window seal in R2's room, and broken blinds in R3's room. Photos were taken and AD Brevet was present and acknowledged the presence of the broken blinds and dusty window seal. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit interview was conducted with Administrator Dao, a copy of this report, LIC811, and appeal rights were provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221109102211

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: LOMITA GUEST HOME	FACILITY NUMBER: 306005508
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/15/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Administrator Brevet cleaned the ceiling fans and had her staff clean the window seal in R2's room.
	8 9 10 11 12 13 14	The requirement is not being met as evidenced by: LPA Haley and AD Brevet Dao observed dust on the ceiling fan in each resident bedroom. LPA Haley and AD Dao observed broken blinds in R2's room, R3's room and the dining room. Further, dirt/dust was observed on the window seal in R2's bedroom.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC9099 (FAS) - (06/04)

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