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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607320
Report Date: 12/10/2024
Date Signed: 12/10/2024 01:47:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241204083016
FACILITY NAME:CERRITOS VILLA 1FACILITY NUMBER:
197607320
ADMINISTRATOR:JULIO NAVALLOFACILITY TYPE:
740
ADDRESS:16231 DRYCREEK LANETELEPHONE:
(562) 404-0767
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 6DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cristina Riego, CaregiverTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff do not ensure care plan for resident is being followed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegation listed above. LPA arrived unannounced and met with Staff, Cristina Riego. The purpose of the visit was explained. Administrator, Julio Navallo, arrived shortly after to assist with the visit.

LPA obtained a copy of the resident roster, staff roster, and documents pertaining to Resident #1 (R1). LPA toured the facility and interviewed the administrator, 4 Staff, family member, hospice nurse, and R1.

For allegation, Staff do not ensure care plan for resident is being followed. It is alleged that Resident #1’s G-tube was clogged due to facility staff not providing the appropriate care. LPA reviewed R1’s file, medical records, and hospice care plan which indicated the reportable conditions pertaining to the G tube complications. R1 was admitted to the facility on 7/9/23 with hospice services for the gastrostomy (G) tube.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 28-AS-20241204083016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320
VISIT DATE: 12/10/2024
NARRATIVE
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Per the administrator and facility staff, R1 is provided food and medications through the G tube. Staff stated they have received training on how to properly flush out the G tube after feeding and clean it. They stated the hospice nurse is responsible for changing the dressing on the G tube. They also stated they contact the hospice agency to report any issues they come across.

Per staff, the G tube had been clogging lately and reported the issue to the hospice nurse, resulting in R1’s G tube being replaced. LPA interviewed the hospice nurse who confirmed that facility staff had been contacting them for any concerns/issues they have on R1. Hospice nurse stated that the G tube had been replaced several times but was not due to facility staff not providing appropriate care. LPA also interviewed R1’s family member who does not have concerns with the care provided by the facility.

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 held. A copy of this report along with the appeal rights was provided to C. Riego.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2