306005712-2-16-2024-22-AS-SSAS-D2P2ZC-20240221165007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005712
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:51:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/17/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231117130230

FACILITY NAME:	VARGAS HOME		FACILITY NUMBER:	306005712
ADMINISTRATOR:	MORA, ANA		FACILITY TYPE:	735
ADDRESS:	2814 WAVERLY AVE		TELEPHONE:	(714) 602-7593
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	6	CENSUS: 5	DATE:	02/16/2024
		UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Facility Administrator - Ana Mora		TIME COMPLETED:	03:16 PM

ALLEGATION(S):

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Facility billed for services not provided to clients
Facility did not follow the client's Admission Agreement
Facility is operating understaffed
Facility is falsifying personnel records
Facility did not maintain accurate Personal and Incidental (P&I) Funds records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Ana Mora.

It was alleged that the facility billed for services not provided to clients. 3 out of the 3 client interviews did not corroborate with the allegation, and 1 out of the 1 staff interview did not corroborate with the allegation by stating the services provided, are the services that are billed. Per documentation review, LPA reviewed the services for the client 1 (C1), client 2 (C2) and client 3 (C3), C1, C2, and C3 verified that the services indicated, were being provided.

It was alleged that the facility did not follow the client's Admission Agreement. 3 out of the 3 client interviews, and 1 out of the 1 staff interview did not corroborate with the allegation by stating that the admission agreement is reviewed and signed prior to a client being admitted into the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231117130230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VARGAS HOME	FACILITY NUMBER: 306005712
	VISIT DATE: 02/16/2024

NARRATIVE

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Per documentation review, LPA observed that each client present, had a signed Admission Agreement, of which all clients interviewed also verified that the admission agreement is being followed.

It was alleged that the facility is operating understaffed. 3 out of the 3 client interviews did not corroborate with the allegation by stating that all needs are met and that there are a total of two staff members present at all times at the facility, and denied of any safety and health concerns. 1 out of the 1 staff interview did not corroborate with the allegation by stating that staff 1 (S1) and staff 2 (S2) are on duty “twenty-four-seven” due to S1 and S2 being live-in staff. LPA reviewed the facility schedule and observed that only S1 and S2 are actively present at the facility, however there are additional staff also available if needed.

It was alleged that the facility is falsifying personnel records. 3 out of the 3 client interviews did not corroborate with the allegation. 1 out of the 1 staff interview did not corroborate with the allegation by stating that all training is valid. Per documentation review, LPA contacted the training agencies on file and was able to verify that the personnel records are valid and legitimate.

It was alleged that the facility did not maintain accurate Personal and Incidental (P&I) Funds records.
3 out of the 3 client interviews and 1 out of the 1 staff interview did not corroborate with the allegation by stating that the facility staff keeps track of each client’s P&I funds via P&I form. Per documentation review, LPA calculated the P&I funds for all clients present at the facility and observed that the amount of funds matched with the form per client, and that the facility notes every time a client is given their P&I funds.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, 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 evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with AD Mora and a copy of this report was provided and explained.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC9099 (FAS) - (06/04)

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