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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604392
Report Date: 12/16/2022
Date Signed: 12/16/2022 11:35:19 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, 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
10/13/2022 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20221013122052
FACILITY NAME:VILLALOBOS ARF #3FACILITY NUMBER:
374604392
ADMINISTRATOR:VILLALOBOS, ROGERFACILITY TYPE:
735
ADDRESS:875 MISTY MEADOW CT.TELEPHONE:
(619) 778-8469
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:4CENSUS: 3DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Myrea SilvaTIME COMPLETED:
11:44 AM
ALLEGATION(S):
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Licensee has not trained staff on clients care needs

Licensee is not following meal plan for client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Direct Support Staff Myrea Silva and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA interviews with facility staff and records review.

It was alleged that Facilty staff did not follow meal plan for client in care (C1) [an LIC 811 Confidential Names List was provided to the facility representative to identify the client] Records review revealed no special diet or meal plan was indicated for C1 by C1's Primary Care Physician. Interview with facility staff revealed none of the clients in the facility have a Doctor's order for a special diet . Interview with Licensee revealed none of the clients that reside in the facility have any special dietary requirements.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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-20221013122052
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: VILLALOBOS ARF #3
FACILITY NUMBER: 374604392
VISIT DATE: 12/16/2022
NARRATIVE
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Licensee further stated that although the clients are not on a special diet, the facility staff make sure to provide the clients meals that are healthy and nutritious.

It was alleged that Licensee has not trained staff on clients care needs (C1). Records review revealed no new medical condition for C1. Interview with staff revealed C1 was being treated by their Doctor for a possible new medical condition. Staff further stated that after tests were completed C1's Doctor advised the facility that C1 did not have the medical condition and C1 would continue on their medications as usual.

Interview with Licensee revealed C1 was being monitored by their Physician for a possible new medical condition. Licensee stated that after tests were concluded, C1's Doctor advised them that C1 would continue on their current medications without the need for any new treatments.

Based on LPA interviews and records review, we have found that the preponderance of the evidence standard has not been met, therefore, the allegation is found to be unsubstantiated.

An exit interview was conducted with Myrea Silva and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Myrea Silva whose signature below confirms receipt of documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2