331880819-1-12-2023-18-AS-DMUN-CNFQQZ-20230126112310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880819
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:17:11 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
01/09/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230109110736

FACILITY NAME:	CALEB HOME		FACILITY NUMBER:	331880819
ADMINISTRATOR:	SAMANTHA PADILLA		FACILITY TYPE:	735
ADDRESS:	49252 PLUMA VERDE PLACE		TELEPHONE:	(760) 601-7307
CITY:	COACHELLA	STATE: CA	ZIP CODE:	92236
CAPACITY:	4	CENSUS: 4	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Ericka Munoz, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not ensure facility TV was in good repair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegation. LPA met with Administrator Ericka Munoz and toured the facility.

LPA interviewed Administrator Munoz, Resident One (R1), Resident Two (R2), and Resident Three (R3). Resident Four (R4) was not feeling well, and was not interviewed.

Regarding allegation, "Staff did not ensure facility TV was in good repair." It was alleged that clients have been without a TV in the main living room since November due to a resident breaking it. Through interviews conducted with staff and residents, LPA found that the TV was broken sometime possibly the week of January 2, 2023, and had been placed in the garage to be discarded at a later date. LPA noticed the broken plug to the TV rendering it not operational. There was not a plan to replace as of this date. Administrator Munoz stated they will replace TV today. Thus, this allegation was SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC811 (confidential names list), LIC9099-D, and Appeal Rights.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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

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
01/09/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230109110736

FACILITY NAME:	CALEB HOME		FACILITY NUMBER:	331880819
ADMINISTRATOR:	SAMANTHA PADILLA		FACILITY TYPE:	735
ADDRESS:	49252 PLUMA VERDE PLACE		TELEPHONE:	(760) 601-7307
CITY:	COACHELLA	STATE: CA	ZIP CODE:	92236
CAPACITY:	4	CENSUS: 4	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Ericka Munoz, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing adequate food service for residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegation. LPA met with Administrator Ericka Munoz and toured the facility.

LPA interviewed Administrator Munoz, Resident One (R1), Resident Two (R2), and Resident Three (R3). Resident Four (R4) was not feeling well, and was not interviewed.

Regarding allegation, "Staff are not providing adequate food service for residents." It was alleged that there hasn’t been food in the facility for approximately four days. During a tour of the facility, LPA noted the facility met the required food supply per the California Code of Regulations. Through interviews conducted, LPA found that grocery shopping is on mondays, and that clients are offered food, and staff save what is made as leftovers. If a client does not want leftovers, they have substitutions that are available along with snacks at anytime. Thus, this allegation was UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that 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 where a copy of this report was discussed and provided along with a LIC811 (confidential names list).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20230109110736

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: CALEB HOME	FACILITY NUMBER: 331880819
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/19/2023 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	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. This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to replace the TV and provide proof of such to LPA by POC date.
	8 9 10 11 12 13 14	Based on observation, LPA found that the TV was broken and not in the living room where residents could enjoy. Licensee did not comply with the regulation. This poses a potential personal rights risk to residents in care.	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.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3