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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607320
Report Date: 09/25/2025
Date Signed: 09/25/2025 12:25:06 PM

Substantiated


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
09/22/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250922154228
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: 2DATE:
09/25/2025
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Julio Navallo - AdministratorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff did not issue a refund to resident's responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Erik Zaragoza and Gabriela Castro conducted an initial unannounced complaint visit to address the allegation listed above. LPAs met with Eppi Vencer, caregiver for the facility, and explained the purpose of the visit. Administrator Julio Navallo arrived shortly thereafter.

The investigation consisted of the following: LPAs obtained the admissions agreement, pre-placement appraisal, physician's report, and FACE sheet for Resident #1 (R1), and interviewed Staff #1 - 2 (S1 - S2).

The investigation revealed the following: In regards to the allegation that "Staff did not issue a refund to resident's responsible party," it is alleged that the responsible party of C1 had paid rent for the entire month of August 2025, and has not received a refund following C1's passing on 8/4/2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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 28-AS-20250922154228
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: 09/25/2025
NARRATIVE
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During the interview with S1, they explained that S2 is in charge of the finances of the facility and is working to arrange the refund for R1's responsible party, however they had been on vacation and are still processing the refund. During interview with S2, they confirmed that they had been on vacation and is still working to determine what the prorated refund for R1's responsible party will be. S2 additionally stated that R1's personal belongings had been removed from the room one (1) or two (2) days after they had passed on 8/4/2025. During record review of R1's admission agreement, it explains that a prorated refund will be issued to the resident's responsible party after the resident's personal belongings are removed from the facility. Based on the Health and Safety Code, the refund of any fees paid in advance for a resident that has passed away shall be issued to the resident's responsible party within fifteen (15) days after the personal property is removed. S2 informed LPAs that the refund will be issued to R1's responsible party on Monday 9/29/2025.

Based on LPA interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Health and Safety Code, Chapter 3.2 Article 6 is being cited on the attached LIC9099D page.

Exit interview was held and a copy of the report along with the appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250922154228
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2025
Section Cited
HSC
1569.652(c)
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(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual (...) contractually responsible for the fees (...) within 15 days after the personal property is removed.
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Licensee/adminisrator is to certfy a plan to address when a refund will be issued to R1's responsible party and provide proof of the refund to R1's responsible party no later than 10/2/2025, via email to LPA Zaragoza.
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This requrement was not met as evidenced by: Based on record review and interview, the facility has not issued a refund to R1's responsible party within 15 days, which poses a potential risk the health, safety, or personal rights of 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: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3