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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600508
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:58:00 PM

Substantiated


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
06/27/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20240627164004
FACILITY NAME:VELASCO HOME IIIFACILITY NUMBER:
374600508
ADMINISTRATOR:ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1549 GRAND TETON COURTTELEPHONE:
(619) 691-0761
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:6CENSUS: 5DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregivers Romy Pino and Gloria Laroza, and Administrator Elizabeth VelascoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee did not help client maintain cleanliness of their wheelchair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation and deliver a finding regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregivers Romy Pino and Gloria Laroza. LPA also spoke via phone with Administrator Elizabeth Velasco during the visit.

It was alleged that Licensee did not help Client #1 (C1) with maintaining the cleanliness of their wheelchair. [See LIC811 Confidential Names List for a description of C1.] CCLD’s investigation involved an unannounced facility tour/welfare check, review of pertinent care and administrative records, and interviews of relevant staff and outside sources. The Department also reviewed multiple third-party photographs received, which were relevant to the allegation.

[CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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-20240627164004
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: VELASCO HOME III
FACILITY NUMBER: 374600508
VISIT DATE: 07/02/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

According to Facesheet, LIC602 Physician’s Report, and San Diego Regional Center (SDRC) care records: C1 was diagnosed with severe intellectual disability and relied on facility staff to help them complete all their Activities of Daily Living (ADLs), to include feeding via a gastronomy. C1 was very confused, not able to follow instructions, and not able to communicate.

Per interview of the Complainant: On two (2) days in late June 2024, and one (1) day in early July 2024, Licensee’s staff allowed C1 to leave the facility for an off-site activity in a dirty wheelchair. Specifically, they said that on each of these three days, there were mice/rat droppings seen on C1’s wheelchair seat/cushion, which they had cleaned up before returning C1 to facility staff.

Interviews of multiple facility caregivers aligned to show: About one month earlier, facility staff saw a rat/mouse inside the facility, which prompted them to lay out traps. Staff successfully caught and disposed of one (1) mouse/rat. They had not seen any such creatures inside the facility since that day. They denied knowing about mice/rat droppings on C1’s wheelchair seat/cushion, and said they cleaned clients’ wheelchairs one per week.

During today’s site visit, LPA was not able to thoroughly inspect C1’s wheelchair seat/cushion, because C1 was actively using/sitting on it. However, photographs received by CCLD strongly corroborated that during the complaint allegation time frame, there were some days when Licensee’s staff did not ensure C1’s wheelchair was clean, allowing C1 to depart the facility with rodent droppings on their wheelchair seat/cushion.

Based on records, interviews, and photographs, a preponderance of evidence exists to show that Licensee did not consistently help C1 with maintaining the cleanliness of their wheelchair. The allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Velasco, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240627164004
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: VELASCO HOME III
FACILITY NUMBER: 374600508
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
85077(a)
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85077 Personal Services: “(a) Licensees shall provide necessary personal assistance and care…” This requirement was not met, as evidenced by:
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Licensee agreed to perform a thorough cleaning/washing of C1’s wheelchair seat and cushion on 07-02-2024. Licensee agreed to educate its staff to check all clients’ assistive mobility devices (and not just their clothing/persons) every morning to ensure their cleanliness before those clients depart for day activities/programs. Licensee agreed to coordinate with a professional pest control company to perform a rodent-specific remediation service at the facility. By the POC due date, Licensee agreed to send proof (such as an invoice or a pest control report) to prove that a professional vendor completed this service.
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Based on records, interviews, and photographs: For 1 of 5 clients (C1), Licensee did not provide necessary personal assistance and care. This posed a potential health and personal rights risks to persons 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/27/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20240627164004

FACILITY NAME:VELASCO HOME IIIFACILITY NUMBER:
374600508
ADMINISTRATOR:ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1549 GRAND TETON COURTTELEPHONE:
(619) 691-0761
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:6CENSUS: 5DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregivers Romy Pino and Gloria Laroza, and Administrator Elizabeth VelascoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Licensee did not take required steps to prevent rodents at facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation and deliver a finding regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregivers Romy Pino and Gloria Laroza. LPA also spoke via phone with Administrator Elizabeth Velasco via phone during the visit.

It was alleged that Licensee did not take required steps to prevent rodents at the facility. CCLD’s investigation involved multiple unannounced facility tours and interviews of relevant staff and outside sources.

Interviews of multiple facility caregivers aligned to show that about one month before the complaint time frame, facility staff saw a mouse/rat inside the facility, which prompted them to lay out traps. Staff successfully caught and disposed of one (1) mouse/rat with said traps. They had not seen any such creatures (or droppings) inside the facility since that day. [CONTINUED ON LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240627164004
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: VELASCO HOME III
FACILITY NUMBER: 374600508
VISIT DATE: 07/02/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-A]

Interviews of caregivers and administrator further corroborated that long before the complaint time frame, Licensee had already contracted a professional outside company to perform preventative pest control services every other month at the facility.

During two (2) visits to the facility, one of which occurred during the complaint allegation time period, and one of which occurred since the complaint was filed, LPA observed: Facility staff consistently kept the kitchen, food preparation, and other food storage areas clean and free of litter and rubbish. Food was correctly stored such that it was not susceptible to rodents. Trash cans and wastebaskets had tight-fitting covers, were in good repair, were leakproof, and rodent-proof. Solid wastes were stored, located, and disposed of in a manner which did not contribute to them becoming a breeding ground for rodents.

According to current regulations, the presence of rodents at a facility, in and of itself, is not a regulatory violation. Regulations instead speak to the maintenance of food areas, covered trash cans, and solid waste practices as the required actionable steps for mitigating rodents. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not take the required steps to prevent rodents at the facility. The allegation is therefore Unsubstantiated, and no deficiency was cited for it.

An exit interview was conducted with Velasco, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5