374604392-5-26-2023-08-AS-SJAB-CSCV77-20230531161039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604392
Report Date: 05/26/2023
Date Signed: 05/26/2023 02:07:03 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
05/10/2023 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20230510103503

FACILITY NAME:	VILLALOBOS ARF #3		FACILITY NUMBER:	374604392
ADMINISTRATOR:	VILLALOBOS, ROGER		FACILITY TYPE:	735
ADDRESS:	875 MISTY MEADOW CT.		TELEPHONE:	(619) 778-8469
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	4	CENSUS: 3	DATE:	05/26/2023
		UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	Administrator Roger Villalobos		TIME COMPLETED:	02:19 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility had expired food

Staff did not meet training requirements

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Administrator Roger Villalobos and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA direct observation, records review, interviews with facility staff and outside agency.

It was reported to CCL that on May 4, 2023 during a visit to the facility, expired food items were found in the kitchen cabinets. It was also reported that staff were not meeting the training requirements. Interview with outside agency revealed on May 4, 2023 they conducted a facility visit and found several expired food items. Outside agency further stated that direct care staff members did not have evidence of receiving 12 hours per year of ongoing continuing education for the years of 2021 and 2022. LPA visit to the facility on May 16, 2023 revealed no expired food items in both the cabinets and refrigerator.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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 3

Control Number 08-AS-20230510103503

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: 05/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA interview with administrator on May 19, 2023 revealed that during an outside agency visit on May 4, 2023 four boxes of expired cake mix were found in the kitchen cabinet and were immediately discarded. Administrator stated that due to the covid-19 pandemic his staff were unable to attend or complete the required staff training. Administrator further stated that all of his staff are currently enrolled in the required training courses and they should be completed in the next several weeks.

Based upon the foregoing, the above listed allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22 and is noted on the attached LIC 9099-D.

An exit interview was conducted with Roger Villalobos and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Roger Villalobos whose signature below confirms receipt of documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20230510103503

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/02/2023 Section Cited CCR 80076(a)(1)	1 2 3 4 5 6 7	In facilities providing meals to clients, the following shall apply: All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.	1 2 3 4 5 6 7	Per Licensee the expired food was immediately discarded upon discovery. Licensee conducted training regarding food service and staff will check food products daily for quality and expiration.
	8 9 10 11 12 13 14	Based on staff and outside agency interviews the licensee did not ensure that the clients were provided safe and quality food. 3 in 3 of 3 persons in care. which posed a potential health risk to persons in care.	8 9 10 11 12 13 14
Type B 06/02/2023 Section Cited CCR 85165(b)(2)	1 2 3 4 5 6 7	Staff who...participate in...manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training...Staff shall maintain valid certification.	1 2 3 4 5 6 7	Per Licensee staff lead is currently in a training class and he will in turn train the remaining staff members. Staff are also enrolled for June training class for 3 CEU's. Licensee will forward signed roster of staff attendance.
	8 9 10 11 12 13 14	Based on staff and outside agency interviews the licensee did not ensure that the staff receive emergency intervention Training .3 in 3 of 3 persons in care. which posed a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3