370804527-5-26-2022-08-AS-SJAB-CEXNLJ-20220531103337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370804527
Report Date: 05/20/2022
Date Signed: 05/26/2022 07:17:53 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/06/2020 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20200706140423

FACILITY NAME:	LIWAG'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	370804527
ADMINISTRATOR:	NORA B. LIWAG		FACILITY TYPE:	740
ADDRESS:	3993 CASEMAN STREET		TELEPHONE:	(619) 690-1022
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92154
CAPACITY:	6	CENSUS: 4	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Licensee Nora Liwag		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Lack of supervision resulting in client on client altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA was met and granted entry into the facility by Licensee Nora Liwag to whom was explained the purposes for the visit.

The Department’s investigation consisted of staff and outside source interviews, and a facility and resident record review.

It was alleged that the above mentioned incident occurred due to lack of supervision. An interview with an outside source and a record review revealed the incident was observed and addressed by facility staff. On June 30, 2020 facility staff observed R1 begin to yell at another resident (R2) and swiftly punched and kicked them one time. R1 then proceeded to their bedroom. Facility staff called R1’s Case Manager who instructed staff to call 911. The police arrived at the facility and placed R1 on a 72 hour hold. An interview with an outside source (OS1) revealed alternative placement is being pursued that can provide a higher level of care due to R1’s aggressive behavior. The facility is fully staffed and there have been no other incidents or substantiated complaints regarding lack of supervision.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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 4

Control Number 08-AS-20200706140423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LIWAG'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 370804527
	VISIT DATE: 05/20/2022

NARRATIVE

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With no other corroborating evidence, the finding regarding the above allegation was established to be unsubstantiated. This finding means although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Licensee Liwag and a copy of the Complaint Investigation Report (LIC 9099) and Licensee Rights (LIC 9058 01-2016) was provided to Licensee Liwag and signature on this report acknowledges receipt of the reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/06/2020 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20200706140423

FACILITY NAME:	LIWAG'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	370804527
ADMINISTRATOR:	NORA B. LIWAG		FACILITY TYPE:	740
ADDRESS:	3993 CASEMAN STREET		TELEPHONE:	(619) 690-1022
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92154
CAPACITY:	6	CENSUS: 4	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	03:30 AM
MET WITH:	LIcensee Nora Liwag		TIME COMPLETED:	04:10 AM

ALLEGATION(S):

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Licensee did not report incident that happened in facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA was met and granted entry into the facility by LIcensee Liwag to whom was explained the purposes for the visit.

The Department’s investigation consisted of a resident and facility record review.

It was alleged that Licensee Nora Liwag failed to report an incident regarding an aggressive act of Resident (R1) (See Confidential Names List LIC 811) toward another Resident (R2) that occurred at the facility on June 30, 2020. However, based on a facility record review, Licensee Liwag submitted a detailed Unusual Incident Report (UIR) and SOC 341 to Community Care Licensing on July 2, 2020, meeting Title 22 reporting requirements. A record review also revealed Licensee Liwag also reported the incident to Law Enforcement and R1’s Case Manager.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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 2

Control Number 08-AS-20200706140423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LIWAG'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 370804527
	VISIT DATE: 05/20/2022

NARRATIVE

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Based on a facility record review the above allegation is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint allegation.

An exit interview was conducted with Licensee Liwag and a copy of the Complaint Investigation Report (LIC 9099) and Licensee Rights (LIC 9058 01-2016) was provided to Licensee Liwag and signature on this report acknowledges receipt of the reports

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2