374603665-7-6-2022-18-AS-DMUN-CHRP4R-20220829105933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603665
Report Date: 07/06/2022
Date Signed: 07/06/2022 02:39:00 PM

Unfounded

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2022 and conducted by Evaluator Tricia Danielson

COMPLAINT CONTROL NUMBER: 18-AS-20220630093411

FACILITY NAME:	DEVON PLACE HOME CARE		FACILITY NUMBER:	374603665
ADMINISTRATOR:	MARK LOO		FACILITY TYPE:	740
ADDRESS:	1814 DEVON PLACE		TELEPHONE:	(760) 941-1818
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 6	DATE:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Nester Blay, Caregiver		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility has a foul odor

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to initiate an investigation into the allegation listed above. LPA met with Caregiver Nester Blay and explained the purpose of the visit. Blay notified Administrator Mark Loo via telephone and LPA spoke with him regarding today's visit.
During today's visit, LPA toured the facility and interviewed three (3) of six (6) residents. Regarding the allegation "Facility has a foul odor", it was alleged that the facility "smelled". The investigation revealed no detectable odor observed by LPA during today's visit. Two (2) of three (3) residents interviewed reported they do not feel the facility has a foul odor. This agency has investigated the complaint alleging "Facility has a foul odor". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

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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