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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602561
Report Date: 02/09/2023
Date Signed: 02/10/2023 08:15:20 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, 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
01/23/2023 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20230123210804
FACILITY NAME:CARELIFE HOMESFACILITY NUMBER:
374602561
ADMINISTRATOR:CASTILLO, SEVEROFACILITY TYPE:
735
ADDRESS:9375 SIMMS COURTTELEPHONE:
(619) 303-0157
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 6DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Caregiver Mary Jane ArnoldTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Medication was accessible to clients
Facility is not safe and/or not in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Caregiver Mary Jane Arnold. Co-Owner Reginald Cosico and Administrator Grace Tizon arrived shortly after.

On January 23rd, 2023, Community Care Licensing (CCL) received a complaint alleging medication was accessible to clients and facility is not safe and/or not in good repair. During the investigation, LPA Strong conducted a facility inspection, collected pertinent records, and conducted interviews.

According to allegations received, C1’s topical medication was found in another client’s bedroom. According to C1’s Physician Report dated January 11th, 2023, C1 is unable to administer or store own medication, report also states C1 can communicate needs. During facility inspection on January 30th, 2023, LPA Strong observed C1’s topical medication stored in C1’s bedroom. According to records reviewed this medication is an as-needed topical medication prescribed by doctors.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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-20230123210804
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: CARELIFE HOMES
FACILITY NUMBER: 374602561
VISIT DATE: 02/09/2023
NARRATIVE
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Continued from LIC9099
During inspection, Administrator acknowledged topical cream should be stored and handed medication to caregiver to be stored with other medications.
Additional allegations received state on January 17th, 2023, the following was seen in the backyard- debris, bags with trash were stacked, water hose was laid out causing a walking hazard, stagnant water in janitor bucket, and gardening tools were accessible to clients. On same date the following was seen indoors -mold was found in the bathroom, water damage was visible in ceiling along with holes in the walls and the light fixtures were not working. During inspection on January 30th, 2023, LPA Strong toured the facility with Administrator and observed the backyard with multiple piles of palm tree debris, trash bags piled outside of the trash receptacle, the water hose was laid across walkway, yellow 8-gallon janitor bucket full of stagnant water and gardening tools throughout the backyard. LPA Strong also observed damage to the bathroom walls, mold on shower curtains and water damage on the ceiling of the bathroom. LPA Strong verified that all light fixtures were functioning at the time of the inspection. During inspection Administrator acknowledged conditions and safety risks expressed by LPA. Interview with administrator revealed that the ceiling water damage is being processed through homeowners’ insurance and a contractor has conducted the assessment to begin repairs. Administrator provided records of homeowners insurance communication to LPA.

Based review of records and observations a preponderance of evidence exists to support the allegation that medication was accessible to client and that facility is not safe and/or not in good repair. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Co-Owner Reginald Cosico and Administrator Grace Tizon, 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: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230123210804
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: CARELIFE HOMES
FACILITY NUMBER: 374602561
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
80075(j)(2)
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Medications shall be centrally stored under the following circumstances: Any medication determined by the physician to be hazardous if kept in the personal possession of the client for whom it was prescribed.
This requirement was not met as evidence by;
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Administrator agrees to conduct a medication storage training for all staff and administrators by 2/23/2023.
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Based on observations, interviews and records reviewed licensee did not keep medication centrally stored in one of six persons in care which posed a potential Health and Safety risk to person in care.
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Type B
02/09/2023
Section Cited
CCR
80087(a)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors
This requirement was not met as evidence by;
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Administrator has cleaned and organized back yard as of 2/9/2023. Plan of correction was cleared on same day.
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Based on observations and interviews the licensee did not maintain a facility in safe and good repair for six of six persons in care which posed a potential health and safety risk 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: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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
01/23/2023 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20230123210804

FACILITY NAME:CARELIFE HOMESFACILITY NUMBER:
374602561
ADMINISTRATOR:CASTILLO, SEVEROFACILITY TYPE:
735
ADDRESS:9375 SIMMS COURTTELEPHONE:
(619) 303-0157
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 6DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Caregiver Mary Jane ArnoldTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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3
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9
Facility does not have a service plan for clients
Facility does not have medical assessment for client
Hazardous items were accessible to clients in care
Facility did not provide quality food necessary to meet the needs of the clients
Administrator is not certified
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Caregiver Mary Jane Arnold. Co-owner Reginald Cosico and Administrator Grace Tizon arrived shortly after.

On January 23rd, 2023, Community Care Licensing (CCL) received a complaint alleging facility does not have a service plan for clients, facility does not have medical assessment for client, hazardous items were accessible to clients in care, facility did not provide quality food necessary to meet the needs of the clients and administrator is not certified.
During investigation, LPA Strong conducted a facility inspection, conducted interviews, and collected pertinent client records. According to allegations, on January 17th, 2023, facility did not have either a medical assessment or an Individual Program Plan for Client 1 (C1) and no medical assessment for Client (C2). During facility inspection on January 30th, 2023, LPA Strong observed an Individual Program Plan dated March 8th, 2022 and two Physician’s Report dated January 11th, 2023 and September 20th, 2021 for C1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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-20230123210804
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: CARELIFE HOMES
FACILITY NUMBER: 374602561
VISIT DATE: 02/09/2023
NARRATIVE
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LPA Strong also observed two Physician’s Report dated January 11th, 2023, and September 20th, 2021 for C2. Interview with administrator revealed that facility had Physician’s Report from 2021 for both clients on hand and was waiting for a fax from medical provider with the most recent report.

It was also alleged that on January 17th, 2023, laundry detergent and wallpaper adhesive were left accessible to clients in care. During facility inspection, LPA Strong did not observe any hazardous chemicals unlocked or accessible to clients in care. Interview with staff present during date in question revealed that two staff were present, one was actively doing laundry, and another was providing direct care to clients. According to staff, laundry detergent was never left unattended and was put away once laundry was loaded. Staff interview also revealed that they did not witness any wallpaper adhesive left out and were unsure of the instance that occurred in.

Additional allegation states that the facility had expired food in pantry. During interviews, staff revealed that on the date in question, there was a can of fruit cocktail that had an expired date. According to staff interview, no expired food was ever served to clients in care and the can was disposed of. Interview with outside source revealed no issues with facility food service. During inspection, LPA Strong inspected items in panty and no items were expired. LPA Strong also viewed enough fresh perishable food to last more than two days and enough nonperishable foods to last more than one week.

Lastly, it was alleged that facility Administrator Certification is expired. LPA Strong verified through the Department of Social Services Administrator Certification application status and found that Administrator submitted application for recertification and is currently pending with an expiration date of October 25th, 2022. During interview with Administrator, it was revealed that another staff member is certified as an Administrator. Records reviewed revealed that such staff is certified as an Administrator with an active certificate. Records also revealed that this staff member has been employed by facility since June of 2019.

Based on LPA's interviews, records reviewed and observations there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Co-owner Reginald Cosico and Administrator Grace Tizon, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5