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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601604
Report Date: 04/09/2022
Date Signed: 04/09/2022 01:05:36 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210301085601
FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:4CENSUS: 4DATE:
04/09/2022
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Roxana Carranza, DSPTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client ingested a glove.
Client meals are not prepared in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ana Soto made an unannounced subsequent visit to deliver findings
and decisions for the above allegations. LPA was met with Roxana Carranza, DSP and the purpose of this visit was explained.

Licensing Program Analyst (LPA) Ana Soto initiated the 10-Day Complaint visit. Due to the situation
surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, the visit
was conducted telephonically with Administrator (Stephanie Larin). The investigation consisted of the
following: On 03/17/22, LPA Soto interviewed S#2. On 03/30/22, LPA Soto interviewed S#1 Area Director & S#3. LPA Soto requested copies of the following documents: face sheets, medication
logs, admission agreements, physician's report, IPP, hospice notes, home health agency notes,
emergency and identification information, house rules, menu, and incident reports for Residents #1- #4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
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 11-AS-20210301085601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 04/09/2022
NARRATIVE
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5
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32
Based on the LPA's investigation, the investigation revealed the following:

For Allegation #1 – Client ingested a glove.
Interviews with S#1 – S#3, stated that R#1 has an existing condition that makes R#1 ingest different
items at any time. LPA Soto reviewed R#1 file, the IPP and Physician’s report do verify that R#1 does
have a medical condition that makes R#1 have those types of behaviors (oral gratification.) LPA Soto
could not interview R#1 – R#4, since the residents could not communicate or understand LPA. The
interviews and record reviews did not concur with the above allegation.

Allegation #2 - Client meals are not prepared in a timely manner.
Interviews with S#1 – S#3, stated that all meals are prepared fresh daily. The staff follows the posted menu and prepare meals accordingly. None of the residents have special diets. S#2 sometimes starts preparing lunch meals in the crock pot early morning, so the food can be finished by lunch time. LPA Soto could not interview R#1 – R#4, since the residents could not communicate or understand LPA. The interviews and record reviews did not concur with the above allegations.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

An exit interview was conducted with Roxana Carranza, DSP and a hard copy of the report was provided
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210301085601

FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:4CENSUS: 4DATE:
04/09/2022
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Roxana Carranza, DSPTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Clients' wheelchairs are broken.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ana Soto made an unannounced subsequent visit to deliver findings
and decisions for the above allegation. LPA was met with Roxana Carranza, DSP and the purpose of this visit was explained.

Licensing Program Analyst (LPA) Ana Soto initiated the 10-Day Complaint visit. Due to the situation
surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, the visit
was conducted telephonically with Administrator (Stephanie Larin). The investigation consisted of the
following: On 03/17/22, LPA Soto interviewed S#2. On 03/30/22, LPA Soto interviewed S#1 Area Director & S#3. LPA Soto requested copies of the following documents: face sheets, medication
logs, admission agreements, physician's report, IPP, hospice notes, home health agency notes,
emergency and identification information, house rules, menu, and incident reports for Residents #1- #4.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
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 11-AS-20210301085601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 04/09/2022
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
Based on the LPA's investigation, the investigation revealed the following.

For Allegation #1 – Clients' wheelchairs are broken. Interviews with S#2, stated that she was the one
that made the request for 2 wheelchairs’ to fixed. She put in a call for the company to go to facility and
repair the wheelchairs. S#1 & S#3, stated that there were a couple of wheelchairs’ that were broken.
They had known that someone was supposed to come in and repair the wheelchairs. They could not
recall when the wheelchairs where repaired. LPA Soto could not interview R#1 – R#4, since the residents
could not communicate or understand LPA. The interviews and record reviews did concur with the
above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of
evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following
deficiency and issued a citation.

An exit interview was conducted with Roxana Carranza, DSP, and a hard copy of report was provided along with Appeal Rights
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210301085601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2022
Section Cited
CCR
85088(g)(2)
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7
85088(g)(2) - Special equipment and supplies necessary to accommodate physically
handicapped persons or other persons with special needs shall be provided to meet
the needs of the handicapped clients
1
2
3
4
5
6
7
Facility to ensure that all wheelchairs are always in working condition.
1
2
3
4
5
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7
1
2
3
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7
1
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7
1
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3
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7
1
2
3
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7
1
2
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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: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5