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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604178
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:14:44 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/11/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20240311171232
FACILITY NAME:CASA DE MAYAFACILITY NUMBER:
374604178
ADMINISTRATOR:GONZALEZ, JOSE A.FACILITY TYPE:
735
ADDRESS:9643 BOTE CTTELEPHONE:
(619) 201-0676
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 3DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Jose Gonzalez, AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Licensee did not meet staff -client ratio for clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted a visit to commence a complaint investigation into the above identified allegation. LPA was granted entry into the facility by Jose Gonzalez, Administrator, to whom LPA disclosed the purpose of the visit. Community Care Licensing (CCL) has investigated the above-listed complaint allegation. The investigation consisted of a review of outside source records and interview of facility staff.
It was alleged that the licensee did not meet staff-client ratio for clients in care. It was reported that, based upon the needs of the clients in care, the licensee was required by San Diego Regional Center to have a minimum of 207 hours for staff for the 3 clients. Interview conducted and a review of outside source records reflected that the hours reported were 151, 161, and 179 which means they were 34 hours short of the required 207 hours for San Diego Regional Center. Records reviewed were from January 2024, which showed the licensee did not have the minimum required number of staff providing client care. Based upon the foregoing, the allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited per California Code of Regulations, Title 22, and are noted on the attached LIC9099-D.
An exit interview was conducted with Jose Gonzalez, and a copy of this report, and Licensee/Appeal Rights (LIC9058) were provided at the conclusion of the visit, their signature on this report acknowledges receipt of copies of the reports and the rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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 2
Control Number 08-AS-20240311171232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE MAYA
FACILITY NUMBER: 374604178
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2024
Section Cited
CCR
80065(a)
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Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidenced by:
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Licensee will provide new time cards/sheets and staff schedules to CCL for the month of February 2024 and March 2024 by 03/30/2024. POC due to CCL by 03/30/2024
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Based on interview and review of records, licensee did not have personnel sufficient in numbers to meet the needs of 3 of 3 clients in care. This posed potential safety and personal rights violations 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: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2