392701350-1-30-2025-27-AS-LKIG-DDRMTC-20250210085315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701350
Report Date: 01/27/2025
Date Signed: 01/30/2025 10:58:33 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2024 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20241230112825

FACILITY NAME:	LA HACIENDA CARE MANTECA, LLC		FACILITY NUMBER:	392701350
ADMINISTRATOR:	VALLARTA, ANABELEN D.		FACILITY TYPE:	740
ADDRESS:	597 HACIENDA AVENUE		TELEPHONE:	(510) 709-7078
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	6	CENSUS: 3	DATE:	01/27/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Tomas Bello		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unfingerprinted staff

Absence of Administrator

INVESTIGATION FINDINGS:

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

Unannounced complaint visit made out to this facility on 01/27/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregiver, Tomas Bello, who was briefly interviewed at this time. This LPA requested that he go ahead and contact the facility Licensee/designated Administrator to inform him/her that CCL was present at this time.
Current census was 3 residents.
The purpose of this visit was to inform this facility, and its representative, that the complaint investigation has been completed with the following findings.
Based on a review of the facility forms and documents, it was observed that there was a total of (6) personnel currently employed at this facility. This LPA requested to review the facility personnel records and was given a total of (6) facility personnel files. It was learned that all (6) facility personnel files did contain proof of the request for Live Scan which was performed and completed for all (6) personnel files.
Based on a review of the facility personnel report in the Licensing Information System (LIS), dated on 01/07/2025, there was only a total of (3) facility personnel currently fingerprint cleared and properly

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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 27-AS-20241230112825

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LA HACIENDA CARE MANTECA, LLC	FACILITY NUMBER: 392701350
	VISIT DATE: 01/27/2025

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

associated at this time. It was learned that there were (3) facility personnel who were not properly transferred and associated to this facility at this time.
Based on interviews, It was learned that the former Administrator, Anabelen Vallarta, was relieved of her duties as the facility designated Administrator on 12/06/2024 and a new facility designated Administrator was appointed shortly thereafter in another letter that was sent out to the residents and their responsible parties. This notification was sent out with the newly appointed facility designated Administrator on 12/09/2024 to this LPA in an email.
Based on a review of the facility forms and documents, the newly appointed facility designated Administrator, S2, did not have any documentation to prove that S2 had been fingerprint cleared and properly associated to this facility since the email notification that was originally sent into CCL on 12/09/2024.
There were no documents made available for review in regards to S2 when facility personnel records were requested at this time.
Based on interviews conducted, it was learned that the newly appointed facility designated Administrator was not present in this facility and has never shown up to this facility whenever CCL has been present for any of the past visits.
It was learned that S2 was currently the only certified Administrator at this time.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Civil penalties were levied and assessed on the following LIC 421BG in the amount of $900.

Appeal rights were printed and a copy was left with the facility designated representative at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20241230112825

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LA HACIENDA CARE MANTECA, LLC	FACILITY NUMBER: 392701350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/28/2025 Section Cited CCR 87355(e)(1-2)	1 2 3 4 5 6 7	All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or	1 2 3 4 5 6 7	The facility representative stated that all facility staff will be reviewed and updated to make sure that they are all fingerprint cleared and properly associated to this facility at all times. A statement of correction, along with updated documented proof of fingerprint clearance
	8 9 10 11 12 13 14	(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This facility was deficient as evidenced by facility staff not being fingerprint cleared and properly associated to this facility. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.	8 9 10 11 12 13 14	and proper association to this facility, will be completed and submitted into CCL by the due date.
Type A 01/28/2025 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate	1 2 3 4 5 6 7	The facility representative stated that the facility designated Administrator will be reviewed and updated to make sure that they are fingerprint cleared and properly associated to this facility at all times. A statement of correction, along with updated documented proof of fingerprint clearance
	8 9 10 11 12 13 14	attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This facility was deficient as evidenced by the facility designated Administrator not being fingerprint cleared and properly associated to this facility with devoted hours of physically being present. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.	8 9 10 11 12 13 14	and proper association to this facility, will be completed and submitted into CCL by the due date. In addition, an updated LIC 500 will be completed to reflect hours of employment and availability for the facility designated Administrator at this facility.

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: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3