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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881313
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:29:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
12/14/2023 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231214155836
FACILITY NAME:TEYRENCE ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
331881313
ADMINISTRATOR:MANALANG, RUBENFACILITY TYPE:
735
ADDRESS:1821 FITZGERALD AVENUETELEPHONE:
(951) 487-6828
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:6CENSUS: DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
03:57 PM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff not providing a healthful environment
INVESTIGATION FINDINGS:
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This is an amended report which reflects new findings previously delivered on LIC9099 dated 10/17/2024.
Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver investigation findings regarding the above allegation. LPA met with Staff, Arsenio Luna, who was informed of the purpose of the visit. The investigation consisted of interviews, documented observations, and records reviews.

Allegation, “Staff not providing a healthful environment”, pertained to several cockroaches running away from Client #1 (C1)’s lunch box. LPA interviewed (2) outside sources who revealed they witnessed bugs on C1’s lunch box on the handle and the top of the lunch box. (1) of (2) outside sources revealed bugs were found on C1’s lunch box on more than one occasion and provided photos.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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
Control Number 18-AS-20231214155836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TEYRENCE ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 331881313
VISIT DATE: 10/30/2024
NARRATIVE
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This is an amended report which reflects new findings previously delivered on LIC9099 dated 10/17/2024.

LPA reviewed photos taken on or around 12/14/2023 which revealed that there were numerous small bugs on a lunch box handle and (1) bug on the top of a lunch box which belonged to C1. LPA received additional photos taken on or around 8/16/2023 were (1) bug was observed in a lunch container that belonged to C1.

LPA conducted (3) client interviews. LPA attempted to conduct an interview with C1, however C1 was not oriented and unable to be interviewed. LPA attempted to interview (2) additional clients, however both clients were non-verbal and unable to be interviewed.

LPA conducted (3) staff interviews. (2) of (3) staff revealed Staff #1 (S1) had packed C1’s lunch on or around 12/14/2023. Interview with S1 revealed they did not observe any bugs inside of C1’s lunch box on or around 12/14/2023. (3) of (3) staff revealed they had not seen bugs in C1’s or any other client’s lunch box and had not received any similar complaints for other facility clients. (1) of (3) staff revealed client lunch boxes are cleaned and placed on top of the facility fridge. LPA conducted facility tour on 12/20/2023 and 10/17/2024. LPA observed no pests during the visits conducted. LPA observed the top of the fridge, floors, drains, kitchen, and facility backyard and did not observe any pests.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 1), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided, along with LIC811, and appeal rights.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20231214155836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TEYRENCE ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 331881313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2024
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds(a)The facility shall be clean...sanitary and in good repair at all times...(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirment was not met as evidenced by:
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The staff agreed to send the a written plan to ensure the outside of the client's lunch box is clean. This is due by the POC due date.
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Based on interview and observation the facility failed to keep the facility free of pests, with C1's lunch box that had insects on the outside of it.
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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: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3