360908446-4-8-2022-18-AS-KCLS-CE43LW-20220503182121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360908446
Report Date: 04/08/2022
Date Signed: 04/08/2022 11:06:20 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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2022 and conducted by Evaluator Bernadette Allen

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220113091353

FACILITY NAME:	JACE GUEST HOME		FACILITY NUMBER:	360908446
ADMINISTRATOR:	YAN, CECILE		FACILITY TYPE:	740
ADDRESS:	11393 YORBA STREET		TELEPHONE:	(909) 628-8640
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	15	CENSUS: 5	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Cecile Yan- Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility did not provide resident personal records per resident's request.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to deliver findings on the above allegation. LPA met Cecile Yan- Administrator

LPA interviewed the licensee and the Administrator about the above allegation. The licensee and administrator both acknowledged receiving the request for Client records from an outside party. They also acknowledged that the records were not provide within a reasonable time frame. Although the documents were eventually sent to the requester, it was not provided in a timely manner per Title 22, Division 6 of the California Code of Regulations.

Based on interviews conducted and documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Cecile Yan- Administrator .

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220113091353

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
, CA 92507

FACILITY NAME: JACE GUEST HOME	FACILITY NUMBER: 360908446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/15/2022 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2(a)(19) Additional Personal Rights of Residents in Privately Operated FacilitiesTo have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the...	1 2 3 4 5 6 7	The licensee has read the personal rights 87468.2(a)(19) at the time of visit and will email statement of understanding of the CCR.
	8 9 10 11 12 13 14	Based on interviews and record review the licensee did not provide resident’s records to authorized representative when requested on 12/15/2021which poses a potential health and safety risk to resident(s) 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: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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