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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005779
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:27:54 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
12/09/2021 and conducted by Evaluator Michelle Reed
COMPLAINT CONTROL NUMBER: 22-AS-20211209113141
FACILITY NAME:PATRICIA HOMEFACILITY NUMBER:
306005779
ADMINISTRATOR:COLLANTES, DELIA B.FACILITY TYPE:
735
ADDRESS:10881 PATRICIA DRIVETELEPHONE:
(714) 624-9933
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:4CENSUS: 3DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Dante BenevictoTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility Administrator failed to assist Resident #1 with his financial benefits.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival, LPA met with Staff Christian Yugale, Teddy Santos and Elmer Hahn. LPA spoke with Administrator Delia Collantes via telephone and explained the purpose of the visit. Ms. Collantes stated that she was not feeling well and could not come to the facility. Assistant Administrator Dante Benevicto arrived a short time later. A tour of the physical plant was conducted and records were reviewed. Resident #1(R1) was admitted into the facility as an emergency placement on 7/23/21. Upon admission, Administrator Delia Collantes was directed by Orange County Regional Center to assist R1 with a change of address and his Social Security benefits. As of today's date Ms. Collantes has not provided assistance and R1 has not received his P & I funds.

Based upon interviews and records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See LIC9099D for cited deficiencies. An exit interview was conducted with Dante Benevicto and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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-20211209113141
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: PATRICIA HOME
FACILITY NUMBER: 306005779
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision-The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Administrator agrees to assist R1 with obtaining his benefits and provide Licensing with her plan and timeframe to do so. Plan should be provided by 12/14/21.
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Administrator failed to assist R1 with a change of address and his Social Security benefits. As of today's date, R1 has not received his P & I funds. This poses an immediate personal rights risk to resident's in care.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2