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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370803166
Report Date: 06/19/2024
Date Signed: 06/20/2024 08:46:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240613151817
FACILITY NAME:MICHAEL GASTELUM A.R.F.FACILITY NUMBER:
370803166
ADMINISTRATOR:GASTELUM, MICHAELFACILITY TYPE:
735
ADDRESS:3705 SINCLAIR LANETELEPHONE:
(619) 465-5208
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 2DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Licensee/Administrator Michael GastelumTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee did not have a current Administrator Certificate
Administrator did not have required training
Confidential records were not kept inaccessible
Licensee did not maintain accurate medication records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to initiate an investigation on the above-mentioned allegations. LPA met with Administrator/Licensee Michael Gastelum and discussed the purpose of the visit.

During investigation, LPA Strong collected pertinent facility documentation and conducted interviews. On June 15, 2024, Community Care Licensing (CCL) received a complaint alleging Administrator did not have a current Administrator Certificate, Administrator did not have required training, confidential records were not kept inaccessible, and licensee did not maintain accurate medication records.

According to first allegation, Administrator to the facility, does not have a current Administrator Certificate. Based on department records reviewed, Administrator does not have a current, or have a pending Administrator Certificate. Outside source records also confirmed Administrator does not have such certificate. Interview with Administrator confirmed they do not have active certificate and do not have a back-up administrator associated to the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 5
Control Number 08-AS-20240613151817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MICHAEL GASTELUM A.R.F.
FACILITY NUMBER: 370803166
VISIT DATE: 06/19/2024
NARRATIVE
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It was also alleged that such Administrator does not have forty hours of continuing education as required. Outside source records revealed that Administrator has not completed continuing education since 2022. Interview with Administrator revealed that due to former client health decline and increased required care, Administrator has not been able to complete continuing education.

Additionally, it was alleged that client records were not safeguarded for confidentiality. Interview with Administrator revealed client records were stored in facility kitchen within an unlocked storage box. Outside source records revealed that on May 8, 2024, client records were stored in an accessible area which does not protect the confidentiality of the clients.

The fourth allegation received states that licensee did not maintain accurate medication records for Client 1 (C1). According to records collected, C1 received verbal medication prescription from medical provider but licensee did not seek written medical prescription and medication administration record was not documented timely. Interview with Administrator revealed they received instructions verbally from medical professional on how to issue medication but did not request an updated prescription in writing. Administrator also reveals that on May 8, 2024, they had not entered C1’s medication administration into forms.

Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Administrator Michael Gastelum, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240613151817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MICHAEL GASTELUM A.R.F.
FACILITY NUMBER: 370803166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2024
Section Cited
CCR
85064.3(d)
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85064.3 Administrator Recertification Requirements(d)To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date.
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Adminsitrator agrees to apply for recertification by plan of correction date and submit proof to LPA via email
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This requirement was not met as evidence by:
Based on interviews and records reviewed the Adminsitrator did not apply for recertification which poses a potential health and safety risk to clients in care.
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Type B
07/17/2024
Section Cited
CCR
85064.3(a)
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85064.3 Administrator Recertification Requirements (a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two-year certification period.
This requirement was not met as evidence by:
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Adminsitrator agrees to complete training by plan of correction date and submit proof to LPA via email
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This requirement was not met as evidence by:
Based on interviews and records reviewed the Adminsitrator complete continuing education which poses a potential health and safety risk to clients 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: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20240613151817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MICHAEL GASTELUM A.R.F.
FACILITY NUMBER: 370803166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2024
Section Cited
CCR
80070(c)(1)
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80070 Client Records (c)All information and records obtained from or regarding clients shall be confidential. (1) The licensee shall be responsible for safeguarding the confidentiality of record contents.
This requirement was not met as evidence by:
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Licensee cleared correction at the time of the visit by locking records.
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Based on records reviewed and interviews the licensee did not maintain records safeguarded for confidentiality in 2 of 2 clients (C1/C2) which posed a potential personal rights risk.
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Type B
07/03/2024
Section Cited
CCR
80070(b)(10)
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80070 Client Records (b) Each record must contain information including, but not limited to, the following (10)Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.
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Adminsitrator provided proof of correcting documents and updated medication labels.
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Based on records reviewed and interviews the licensee did not maintain medication records in 1 of 2 clients (C1) which posed a potential health and safety risk to clients 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: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240613151817

FACILITY NAME:MICHAEL GASTELUM A.R.F.FACILITY NUMBER:
370803166
ADMINISTRATOR:GASTELUM, MICHAELFACILITY TYPE:
735
ADDRESS:3705 SINCLAIR LANETELEPHONE:
(619) 465-5208
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 2DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator Michael GastelumTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
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9
Licensee did not maintain client financial record
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate an investigation in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Adminsitrator/Licensee Michael Gastelum.
During investigation, LPA Strong collected pertinent facility documentation and conducted interviews. On Junw 15, 2024, Community Care Licensing (CCL) received a complaint alleging licensee did not maintain client 1 (C1) and client 2 (C2) cash resouces documentation accordingly. C1 and C2's Physicians Reports both state that they are able to maintain own cash resources. Interview with Administrator revealed that they do not keep or maintain client's money and therefore do not maintain LIC 405.
Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5