374604321-9-29-2023-08-AS-SJAB-CW5V24-20230929160230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604321
Report Date: 09/28/2023
Date Signed: 09/29/2023 10:00:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2020 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20200723150427

FACILITY NAME:	SANTA FAUSTINA ARF		FACILITY NUMBER:	374604321
ADMINISTRATOR:	BEALS, SUSAN		FACILITY TYPE:	735
ADDRESS:	227 BAVARIA DR		TELEPHONE:	(760) 806-9616
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Arlene Valenzuela House Manager		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility is over capacity
Absence of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding in the above mention complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with House Manager Arlene Valenzuela.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents and outside sources.

It was alleged that the facility was over capacity. LPA Domingo reviewed records during the months of 01/01/2020 through 08/30/2020 and the facility capacity coincided with the facility license of 6 Residents. Outside Source 1 (OS1) (See LIC811 Confidential Names list)

[Continued on LIC9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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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Control Number 08-AS-20200723150427

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SANTA FAUSTINA ARF	FACILITY NUMBER: 374604321
	VISIT DATE: 09/28/2023

NARRATIVE

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[Continued from LIC9099]

was interviewed and verbalized that the facility at the time of the report had 5 Residents. Staff 1 (S1) was interviewed and also verified that there were only 5 Residents at the time of the report. Staff 2 (S2) was interviewed and also stated that the facility had 5 residents at the time of the report. There have been no evidence from records review and interviews that the facility was caring for more than 6 residents since the facility opened and licensure was approved.

It was alleged that there was an absence of supervision of residents. LPA Domingo reviewed facility records and verified that the facility provided staff supervision at all times when residents were present. S1 was interviewed and stated that the residents have continued supervision at all times when at the facility. OS1 was interviewed and stated that through observation the staff was present when residents were present.

Based on LPA's interviews with Residents, outside source interviews, and records reviewed there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with House Manager, 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: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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