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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880747
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:41:47 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, 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: 3DATE:
12/13/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Shayla Rodriguez - AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not provide adequate food service for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to deliver findings on an open complaint investigation with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Shayla Rodriguez. Below is a summary of the complaint investigation findings:

Regarding allegation "Facility did not provide adequate food service for residents": LPA Colvin reviewed facility documents and condcuted interviews with staff regarding the meals that are served and provided at the facility. LPA Colvin obtained a copy of one of the facility's weekly menus, and confirmed with staff that it was accurate as to what was being served. LPA Colvin observed that numerous meals do not meet the USDA requirements for a nutritous meal. An example of meals which do not meet this requirement are: Breakfast - waffles & sausages; Breakfast - scrambled eggs with a side of hashbrowns; Lunch - ham sandwhich; Lunch - cucumber salad; Dinner - Grilled chicken and corn on the cobb; Dinner - Ground beef ans cauliflower rice. These items were taken all from a single week's menu at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
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 5
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: 12/13/2022
NARRATIVE
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Many of these meals are missing important components all together, such as 2 servings of fruits/vegetables, 4 servings of grain, and 2 servings of milk & milk products. Since the facility menu sample provided to LPA Colvin was stated to be accurate to what the residents are being served, and several meals are missing entire food groups which are recommended by the USDA to be served at each meal, the allegation "Facility did not provide adequate food service for residents" 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 Administrator Shayla Rodriguez during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited
CCR
80076(a)(1)
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Food Services: (a) In facilities providing meals...the following shall apply: (1) ...Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served... This requirement was not met as evidenced by:
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Licensee agrees to re-evaluate the facility's menu (LPA reccomends consutling a nutritionist) and create a new menu which meets the residents' dietary requirements. Licensee to submit new menu to LPA Colvin by Plan of Correction date of 12/30/22.
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Based on interviews and record review, the Licensee did not comply with the above regulation. LPA Colvin observed numerous meals to not have required components (as deemed by USDA), such as grain, fruit/veggies, o milk products. This is a potential health risk to residents 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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 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, 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: DATE:
12/13/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Shayla Rodriguez - AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not intervene when a resident threatened another resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to deliver findings on an open complaint investigation with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Shayla Rodriguez. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff did not intervene when a resident threatened another resident in care": LPA Colvin reviewed facility records and conducted interviews with staff regarding a specific incident which occurred on 7/20/22. LPA Colvin confirmed that on 7/20/22, resident 1 (R1) was being verbally aggressive with staff when resident 2 (R2) stepped in and told R1 to not speak to staff that way. R1 then followed R2 back to R2's room and attempted to break down R2's bedroom door. LPA Colvin observed in R1's Behavioral Support Plan that when R1 is participating in maladaptive behaviors (such as aggression), that the staff's intervention is to verbally redirect the resident. LPA Colvin interviewed staff regarding the incident and all interviews confirmed that staff verbally redicted R1 when R1 was targeting R2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 12/13/2022
NARRATIVE
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It is additionally prudent to note that R1 no longer resides at the facility and was given a 30-day eviction notice due to the facility not being able to handle R1's level of behaviors. Therefore, the allegation "Staff did not intervene when a resident threatened another resident in care" is UNSUBSTANTIATED

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Administrator Shayla Rodriguez and a copy of this report was provided..
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5