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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604036
Report Date: 01/05/2023
Date Signed: 01/12/2023 03:27:04 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
12/30/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20221230164015
FACILITY NAME:BEST ELMDALE RCFFACILITY NUMBER:
374604036
ADMINISTRATOR:HILTON. JAZMINFACILITY TYPE:
735
ADDRESS:10330 ELMDALE DRTELEPHONE:
(619) 501-7785
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 4DATE:
01/05/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Enrique Bettancourt TejedaTIME COMPLETED:
05:48 PM
ALLEGATION(S):
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-Medication not given as prescribed
-Hazardous items were accessible to clients in care

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above mentioned allegations. LPA was greeted and allowed entry into the facility by Staff, Enrique Bettancourt Tejeda. LPA met with Staff, Jessica Sosa and Staff, Sandra Campbell. LPA spoke with Administrator, Celina Brown via telephone to discuss allegations.

During the investigation, a tour of the facility was conducted, along with record review and interviews with staff, clients, and outside sources. It was alleged Client #1 (C1) was not given medication as prescribed. C1’s Physician’s Report, dated 10/06/21 indicated C1 cannot store or manage their own medications. Interviews with outside sources revealed on 12/20/22, a medication error was observed for C1. C1's bubble pack for 12/13/22 still had the pill in the bubble pack, as it was not dispensed. Staff interviews revealed C1 does not attend day program. Therefore, C1 typically leaves with staff from 8am-1pm. Staff interviews revealed they assumed the staff that was present with C1 took the medication with them. Due to miscommunication, C1 did not receive their prescribed medication on 12/13/22. Continued on an LIC 9099C. This is an amended version of the original report created on 01/05/22.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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-20221230164015
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: BEST ELMDALE RCF
FACILITY NUMBER: 374604036
VISIT DATE: 01/05/2023
NARRATIVE
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Staff interviews confirmed C1 did not receive their prescribed medication and since the incident, staff communicate better regarding C1's medications.

It was also alleged, hazardous items were accessible to clients in care. It was reported, the following items were observed on 12/20/22 as accessible to clients in care: laundry detergent and bleach above the washer/dryer; cleaning supplies under the kitchen sink; and toiletries and cleaning supplies in a hallway cabinet. Title 22 Regulations outlines cleaning solutions that pose a danger if readily available to clients shall be stored where inaccessible to clients. The cabinet in the hallway had a padlock, but not in use, making all the hazardous items accessible to clients. Staff interviews revealed the locks were broken on the cabinets and once made aware, all new locks were purchased. Client interviews revealed the cleaning supplies are locked. During today's visit, LPA observed new locks on all the cabinets that store toxins, making them inaccessible to clients in care.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 1 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Staff, Enrique Bettancourt Tejeda whose signature below confirms receipt of these rights. LPA discussed plan of corrections vis telephone with the administrator. This is an amended version of the original report created on 01/05/22.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 08-AS-20221230164015
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: BEST ELMDALE RCF
FACILITY NUMBER: 374604036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2023
Section Cited
CCR
80075(b)
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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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Administrator scheduled medication training for staff with a vendorized pharmacy during the visit. Administrator will submit proof of training once completed.
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Based on interviews, the licensee did not ensure (C1) 1 out of 4 clients received their medications as prescribed. This posed a potential health and safety risk to clients in care.
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Type A
01/06/2023
Section Cited
CCR
80087(g)
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Buildings and Grounds- Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Staff stated they will conduct In-Service training on hazardous items that could pose danger be made inaccessible to clients in care. Administrator scheduled training and will provide proof of training within 2 weeks.
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Based on interviews, the licensee did not make hazardous items inaccessible to 4 out of 4 clients in care. This posed an immediate 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2023
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
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
12/30/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20221230164015

FACILITY NAME:BEST ELMDALE RCFFACILITY NUMBER:
374604036
ADMINISTRATOR:HILTON. JAZMINFACILITY TYPE:
735
ADDRESS:10330 ELMDALE DRTELEPHONE:
(619) 501-7785
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 4DATE:
01/05/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:TIME COMPLETED:
05:48 PM
ALLEGATION(S):
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-Facility did not provide the quality of food necessary to meet the needs of the clients
-Facility is not following video surveillance guidelines
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above mentioned allegations. LPA was greeted and allowed entry into the facility by Staff, Enrique Bettancourt Tejeda. LPA met with Staff, Jessica Sosa and Staff, Sandra Campbell. LPA spoke with Administrator, Celina Brown via telephone to discuss allegations.

During the investigation, a tour of the facility was conducted, along with record review and interviews with staff, clients, and outside sources. It was alleged the facility did not provide the quality of food necessary to meet the needs of the clients. Outside source interviews revealed observing on 12/20/22, sandwich meat that turned brown; hot dogs that had a use by date of 10/11/22; and sandwich meat that said sell by 11/18/22. Staff interviews revealed the items were taken out of the freezer and placed in the fridge. Staff stated the items were not expired as they were properly stored in freezer. A review of the USDA website indicated hotdogs and lunchmeat can be stored in the freezer at 0 degrees F. for 1-2 months. Client interviews revealed they have not been served brown meat. Additional client interviews revealed the food served looks good and tastes good. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20221230164015
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: BEST ELMDALE RCF
FACILITY NUMBER: 374604036
VISIT DATE: 01/05/2023
NARRATIVE
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Lastly, it was alleged the facility is not following video surveillance guidelines. Outside source interviews revealed observing a camera in the living room area. Today, LPA observed multiple cameras throughout the facility in common areas only. Administrator's interview revealed the cameras are non-operational. Administrator stated they will discuss removing the cameras. LPA made the Administrator aware of video surveillance guidelines.

During the course of the investigation interviews were conducted along with observations. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Staff, Enrique Bettancourt Tejeda whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5