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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604392
Report Date: 03/27/2024
Date Signed: 03/27/2024 01:17:05 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
01/05/2024 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20240105090128
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:
03/27/2024
UNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Rosamaria HalogTIME COMPLETED:
01:24 PM
ALLEGATION(S):
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Staff did not treat client with dignity
Staff did not provide meals to client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Caregiver Rosamaria Halog 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 interviews with facility staff, clients and outside sources.

It was alleged that facility staff did not treat Client 1 (C1) with dignity. [an LIC 811 Confidential Names List was provided to the facility representative to identify the client] It was reported that facility staff verbally abused C1. It was also reported that facility staff withheld food from C1. LPA spoke with C1 at C1's day program. C1 stated that the facility staff make C1 food but sometimes C1 doesn't like it. C1 further stated that C1 is "too lazy" to make C1's own food. C1 stated that facility staff cursed at C1 and C1's mother.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
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-20240105090128
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: 03/27/2024
NARRATIVE
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Interview with outside source (OS) revealed C1 has a tendency to become problematic when C1 meets other clients at the day program C1 attends. C1 is encouraged by other clients to move out of C1's facility and into the facility of the new client C1 has met. OS stated that this is an ongoing issue with C1. OS stated that they have no knowledge of any staff cursing or verbally abusing C1 at the facility. OS further stated that they do not believe that facility staff is withholding food from C1.

Interview with outside source II (OSII) revealed OSII spoke with C1 about an allegation C1 made regarding staff cursing at C1. OSII stated that C1 retracted the allegation and statements C1 previously made. In regards to staff not providing food for C1. OSII stated that their was an instance where staff made breakfast and C1 did not want to take the food with them to their day program. C1 arrived to the day program and advised the staff that C1 was hungry and was not fed. OSII stated that to avoid this happening again facility staff gives C1's food directly to transportation, so C1 can eat their food at the day program. OSII further stated that she has never witnessed staff cursing at C1 but she has witness C1 misinterpret situations. OSII stated that C1 has a tendency to get information "jumbled."

LPA interviewed C1's responsible party (RP). RP stated that facility staff have never cursed at her or C1. RP stated that the facility staff treat C1 very well. RP stated that facility staff contact her to calm down C1 when C1 becomes upset or irate. RP further stated that the facility staff do not withhold food from C1 and she eats well at the facility.

Interview with Administrator revealed that C1's stay at the facility is the longest that C1 has resided at any Adult Residential Facility. Administrator stated that C1 often meets people on social media that encourage C1 to leave the facility. C1 often gets upset with staff that advise C1 of the dangers of meeting strangers on the internet. Administrator stated that C1 also regularly gets upset and "fights" with their mother. Administrator stated that C1's day program has advised him that C1 cusses at the other clients and C1 has accused the other clients of calling C1 inappropriate names. Administrator further stated that C1 has called the police several times when C1 wants to leave the facility. C1 tells the police that C1 "didn't feel good." Administrator stated that the staff do not curse or verbally abuse C1. Administrator stated that C1 has the option of making C1's own meals or eating the food that the staff prepares. Administrator stated that staff never deny C1 food and C1 will sometimes refuse the food prepared by staff because C1 doesn't like it.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240105090128
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: 03/27/2024
NARRATIVE
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Based on LPA interviews we have found that the preponderance of the evidence standard has not been met, therefore, the allegations are found to be unsubstantiated.

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

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3