374604392-7-26-2023-08-AS-SJAB-CU6THG-20230728144444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604392
Report Date: 07/26/2023
Date Signed: 07/26/2023 01:56:24 PM

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
06/21/2022 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20220621080420

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:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	01:31 PM
MET WITH:	Roger Villalobos		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Absence of Supervision

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 allegation. 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 allegation. The investigation consisted of LPA direct observation and interviews with facility staff and outside agencies.

It was reported to CCL that on May 11, 2022 an outside agency received telephone calls from multiple clients advising them that they were alone in the facility with no staff present. LPA unannounced visit to the facility on June 21, 2022 and July 17, 2023 found clients under the direct supervision of facility staff.

Interview with outside agency revealed on May 11, 2022 they received telephone calls from multiple clients advising her that they were alone in the facility with no staff present.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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-20220621080420

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: VILLALOBOS ARF #3	FACILITY NUMBER: 374604392
	VISIT DATE: 07/26/2023

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

Outside agency further stated that the Adult Day Program dropped off the clients at the facility in the afternoon and facility staff were not present to receive them. Outside agency stated that as a result the facility received a six month sanction.

Interview with outside source revealed the clients were dropped off at the facility on May 11, 2022 by adult day program transportation staff. Outside source stated that the front door of the facility was unlocked and the clients walked into the facility. Transportation staff were unaware that their were no staff present inside the facility. Outside source further stated that as a result of the incident, transportation staff are instructed to visually "hand off" clients to facility staff to prevent absence of supervision.

Interview with administrator revealed that although the absence of supervision did take place they had an explanation. Administrator explained that for may years facility staff were scheduled to start at 2:00 pm, with consumers getting out of their Day Program at 2:00 pm. Staff would be at the facility already to accept them as they would came in anytime between 2:20 to 3:00 pm. Then without notice consumers started showing up at 2:00pm or earlier, so they made adjustments to their staffing to start at 1:30pm as to have staff coverage as clients arrived. Then in early 2022, clients started to show up from their Day Program as early as 1:10 pm or 1:15pm and they were caught off guard and not warned or notified that consumers were being let out earlier on a daily basis.

Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is 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: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220621080420

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: VILLALOBOS ARF #3	FACILITY NUMBER: 374604392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/04/2023 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will attend training along with staff regarding client supervision and provide proof of training by 8/4/23.
	8 9 10 11 12 13 14	Based on interviews the licensee did not provide supervision for two out of three clients by leaving the clients unsupervised at the facility. This posed a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3