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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604178
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:12:59 PM

Unsubstantiated


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
04/03/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20240403130808
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:
04/05/2024
UNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Jose Maya, AdministratorTIME COMPLETED:
12:37 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client medication records were not complete
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 client medication records were not complete. It was observed by an outside agency that Client 1 (C1)s Medication Administration Record (MAR) record did not contain a list of all of the medications prescribed to client and their side effects. Interviews revealed the side effects leaflets were in another binder at the time and was provided to the outside agency at the time they were observing the files. Interviews revealed that staff moved the documents from the alternate binder into the Mars binder within the next two days. Interviews with staff revealed the leaflets were in the garage in the other binder. The allegation is unsubstantiated.

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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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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