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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880747
Report Date: 07/25/2022
Date Signed: 07/25/2022 11:47:50 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220721081333
FACILITY NAME:CHIHUAHUA HOMEFACILITY NUMBER:
331880747
ADMINISTRATOR:WEST COAST CARE PROVIDERSFACILITY TYPE:
735
ADDRESS:77595 CALLE CHIHUAHUATELEPHONE:
(442) 256-4174
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:4CENSUS: 4DATE:
07/25/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dora Arreloa - Facility StaffTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with staff Dora Arreloa. Below is a summary of the complaint investigation findings:

Regarding allegation "Facility is in disrepair": LPA Colvin conducted a tour of the facility and interviewed present staff members. Upon arrival to the facility, LPA Colvin observed that there was no facility vehicle parked in front of the house or in the garage. LPA Colvin inquried with staff about the lack of vehicle, and was informed that the van is "in the shop" and has been out of order since at least last Tuesday. LPA Colvin inquired as to if staff use their personal cars to transport residents at this time, and staff stated that the Licensee's other facilities use their facility vehicles to assist with transportation of the residents. LPA Colvin observed that 2 of the 4 residents that live at the facility were at Day Program, so if the facility were to need to pick up the two residents unexpectedly, they would be unable to do so, if nearby facilities are not available.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
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 4
Control Number 18-AS-20220721081333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHIHUAHUA HOME
FACILITY NUMBER: 331880747
VISIT DATE: 07/25/2022
NARRATIVE
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The other item noted in the complaint to be out of working order at the facility is the second refrigerator, which is located in the garage. Upon inquiring with staff about food storage, LPA Colvin was informed that the only working refrigerator was in the kitchen at this time. LPA Colvin inquired about additional refrigerators and was informed that there is a non-operational refrigerator in the garage which staff would usually use to store their personal food, but that it has not been working for at least one month. LPA Colvin was granted access to the garage to inspect the broken refrigerator and observed it to have a sign posted on the outside stating "out of order". LPA Colvin opened the refrigerator and was promptly greeted with a foul odor and observed the refrigerator to be dirty (though empty) and had a pool of dark liquid sitting in the bottom drawer of the left-hand side. LPA Colvin inquired with staff as to what the plan with the refrigerator in the garage was, as it has been sitting non-operational in there for a month. Staff stated they did not know, and that the Licensee was either going to have it fixed, replaced, or removed.

Due to LPA Colvin's observations and interviews confirming the refrigerator in the garage being broken for at least one month and the facility vehicle being non-operational for at least one week, the allegation "Facility is in disrepair" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to facility staff Dora Arreloa during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220721081333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHIHUAHUA HOME
FACILITY NUMBER: 331880747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2022
Section Cited
CCR
80087(a)
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Buildings and Grounds : (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. Thsi requirement was not met as evidenced by:
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Licensee agree to have broken items (facility vehicle and garage fridge) replaced (fridge may be removed) or repaired. Licensee to provide LPA Colvin with receipts showing replacement or repair (or photographs pf removal of fridge) by the Plan of Correction date of 8/8/22.
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Based on observation and interview, the Licensee did not comply with the above allegation with two items of facility equipment. LPA Colvin confirmed that the secondary refrigerator in the garage and facility vehicle are both in non-operational condition. This poses a potential safety risk to residents.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4