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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200735
Report Date: 06/07/2024
Date Signed: 06/07/2024 12:43:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240531085551
FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:JOSEPH FARRISH IIIFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:4CENSUS: 3DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Joseph Gapasin, Administrator TIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff did not ensure that a resident's care needs were met
INVESTIGATION FINDINGS:
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On this day around 9:25am Licensing Program Analysts (LPAs) K. Nguyen and A. Gharachorloo arrived to conduct visit on the above allegation. LPAs met with administrator (AD), Joseph Gapasin and discussed the reason for visit.
Allegation: Staff did not ensure that a resident's care needs were met- Substantiate
During investigation LPAs interviewed administrator, reviewed client files, and facility home chore list for the month of May. Facility administrator confirmed that the above allegation is true, due to R1 vomit was not being clean during the time it happened. AD indicated that the staff did not being responsible and left R1, but there where another staff that was present with R1.
The investigation alleging staff did not ensure that a resident’s care needs were met. We have found that the complaint is SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.
Exit interview is conducted and a copy of this report is provided via email including the LIC 9099D. An appeal rights is provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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 2
Control Number 15-AS-20240531085551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA MENTOR - MALABAR HOME
FACILITY NUMBER: 019200735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidence by:
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Administrator will review the regulation and conduct an inhouse training to all staff with the training agenda attach with all staff signature and submit to CCLD by POC date.
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Based on interview and records review, Administrator failed to ensure that a resident’s care needs were not met, which poses a potential health, safety or personal rights risk to persons in care.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2