374604444-6-17-2024-08-AS-SJAB-D6ELZ7-20240620091124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604444
Report Date: 06/14/2024
Date Signed: 06/17/2024 03:13:44 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
05/15/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20240515143802

FACILITY NAME:	SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIAL		FACILITY NUMBER:	374604444
ADMINISTRATOR:	OKORO, KINGSLEY		FACILITY TYPE:	740
ADDRESS:	5711 BOUNTY STREET		TELEPHONE:	(619) 916-6114
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 5	DATE:	06/14/2024
		UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Kingsley Okoro Administrator		TIME COMPLETED:	12:14 PM

ALLEGATION(S):

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Licensee did not keep the facility free from pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced complaint investigation at the facility regarding the above allegation. LPA was greeted at the front entrance by House Manager Lola Okoro, identified herself, and was granted entry into the facility. LPA Domingo explained the purpose of the visit and the elements of the complaint with Administrator Kingsley Okoro and Lola Okoro House Manager.

The Department’s investigation consisted of resident records reviewed, interviews with staff, residents and outside sources and a tour of the facility.

On May 15, 2024, it was alleged that staff did not ensure facility was free from pests. More specifically, it was alleged the facility had pests. Interviews with outside sources confirmed that there were 2 pests inside one of the resident drawer.

[Continue on LIC9099C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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 5

Control Number 08-AS-20240515143802

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: SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIAL	FACILITY NUMBER: 374604444
	VISIT DATE: 06/14/2024

NARRATIVE

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[Continued from LIC9099]

Interviews with staff, outside sources and outside records reviewed confirmed the facility had an inspection on June 3, 2024 that discovered a pest leg. LPA observed round black specs on the window sill of a residents room during the 2 unannounced visits. There were multiple images collected that appeared to show pests droppings on the window sill of the resident room.

The Department has investigated the allegation of staff did not keep facility free from pests. Based on evidence obtained, the allegation is substantiated which means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D.

An exit interview was conducted with Licensee and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 3/22) was provided. Licensee signature below confirms receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
05/15/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20240515143802

FACILITY NAME:	SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIAL		FACILITY NUMBER:	374604444
ADMINISTRATOR:	OKORO, KINGSLEY		FACILITY TYPE:	740
ADDRESS:	5711 BOUNTY STREET		TELEPHONE:	(619) 916-6114
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 5	DATE:	06/14/2024
		UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Kingsley Okoro Administrator		TIME COMPLETED:	12:14 PM

ALLEGATION(S):

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Insufficient staffing to meet Resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced complaint investigation at the facility regarding the above allegations. LPA was greeted at the front entrance by House Manager Lola Okoro, identified herself, and was granted entry into the facility. LPA Domingo explained the purpose of the visit and the elements of the complaint with Administrator Kingsley Okoro.

The Department’s investigation consisted of resident records reviewed, interviews with staff, residents and outside sources and a tour of the facility.

On May 15, 2024, it was alleged that the licensee did not have amble staff during the evening hours. LPA reviewed the staff schedules for the month of April 2024, May 2024 and June 2024 and the schedule reflected what was needed to care for the residents in the facility.

[Continue on LIC9099C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20240515143802

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: SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIAL	FACILITY NUMBER: 374604444
	VISIT DATE: 06/14/2024

NARRATIVE

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[Continued from LIC9099]

A review of staffing schedules indicated sufficient staffing. Staff interviews confirmed the facility had sufficient staffing. Staff also stated if a staff member calls out then the existing staff will work over one to two hours or a manager will assist. Resident interviews expressed their needs are met and when they call for assistance their is staff to help. Outside source interviews revealed the facility had sufficient staffing. The facility ensured sufficient staff were present to meet the residents’ needs.

The Department has investigated the allegation of Insufficient staffing to meet resident's needs. Based on evidence obtained, the allegation is unsubstantiated which means that the allegation is invalid because the preponderance of the evidence standard has been met.

An exit interview was conducted with the Administrator and a copy of this report, and Licensee/Appeals Rights (LIC 9058 3/22) was provided. Administrator signature below confirms receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20240515143802

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: SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIAL	FACILITY NUMBER: 374604444
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors as evidenced by:	1 2 3 4 5 6 7	Licensee is working with a professional pest control company. The pest control is scheduled to visit the facility on 6/18/24. Licensee will submit invoice to CCL by 6/19/2024. Licensee agrees to work with a professional pest control company to come out to the facility until the pests are eliminated.
	8 9 10 11 12 13 14	Based on observations and multiple images, the licensee did not provide a clean or sanitary environment due to evidence of pest droppings and images of pests. This poses a potential health risk to four of the four 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.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5