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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610008
Report Date: 05/19/2024
Date Signed: 05/19/2024 04:28:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240124103329
FACILITY NAME:HUMBLE HAVEN RCFE IIFACILITY NUMBER:
197610008
ADMINISTRATOR:ALAS, NICOLE DE LASFACILITY TYPE:
740
ADDRESS:37801 RUDALL AVE.TELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:6CENSUS: 3DATE:
05/19/2024
UNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Jan Allen Vernon De Jesus TIME COMPLETED:
11:49 AM
ALLEGATION(S):
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Licensee does not dispense medication as prescribed to resident in care.
INVESTIGATION FINDINGS:
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On 05/19/24, Licensing Program Analyst (LPA) Ernand Dabuet made a subsequent unannounced visit to this facility and was greeted by caregiver staff #1 (S1) Jan Allen Vernon De Jesus. LPA Dabuet contacted the administrator Nicole De Las Alas who was not available for this visit. LPA explained the purpose of today’s visit is to gather information for the allegation mentioned above and deliver findings.

The investigation consisted of the following: An initial 10-day visit was conducted by (LPA) Melissa Spaeth on 01/31/24 who met with caregiver Melina Serrano. (LPA) Dabuet conducted subsequent visits on 05/18/24 and 05/1924. (LPA) Dabuet requested copies of files for resident #1 (R1)’s Admissions Agreement (dated: xx xx xx), Physicians Report LIC 602A (dated: 12/20/23), Register of Facility Residents LIC 9020 (dated: 02/29/24), and other documents associated with the complaint. Interviews were conducted with residents #1-#2 (R1-R2), staff #1 (S1), and administrator #1 (A1). A tour of the facility was performed.
(Evaluation Report continues LIC 9099-C) 
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
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 5
Control Number 31-AS-20240124103329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
VISIT DATE: 05/19/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff abandoned resident at hospital.

The details of the complaint alleged facility staff abandoned the resident at the hospital. The complainant reported resident #1 (R1) was admitted on 01/18/24 and that home care staff refused to accept (R1) back at the facility. The complainant stated that (R1) does not require additional higher level of care needs. The complainant reported when the hospital reached out to coordinate (R1) release and was informed by staff that (R1) could not return.

According to resident #1 (R1)’s Admissions Agreement Residential Care Facilities for the Elderly is self-responsible and did not have a conservator, power of attorney, or guardian. Admissions Agreement revealed to be unsigned and undated by (R1) and facility representative.

On 01/17/24 at 12:55 pm, Licensing Program Analyst (LPA) Melissa Spaeth interviewed resident #1 (R1). (R1) claimed to be an Assisted Living Waiver (AWL) recipient and should have not to pay anything. (R1) claimed to dispute the additional cost the administrator is charging. (R1) did not sign the Admissions Agreement due to the cost dispute. (R1) reported that the administrator issued (R1) a 30-day Eviction Notice on 01/11/24. (R1) claimed the administrator is attempting to evict (R1) based on non-payment. (R1) stated to have been placed in the facility on 12/20/24.

On 05/18/24, between 02:45 pm – 03:31 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1) by telephone. (A1) confirmed that (R1) was a resident at the facility and the facility provided care and supervision services for approximately 29 days. (A1) reported to have issued a 30-day Eviction Notice to (R1) in person served by a care staff. (A1) claimed to have notified Community Care Licensing (CCL) of the eviction by faxing the Eviction Notice to the Woodland Hills South Adult and Senior Care Regional Office. (A1) was uncertain of the date the notice was dated and issued nor the date it was sent to (CCL). (A1) did not follow up with the (WHS) Regional office to determine if notice was received or was authorized for approval.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20240124103329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
VISIT DATE: 05/19/2024
NARRATIVE
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(A1) communicated that (R1) was an AWL and SSI recipient and that (R1) was evicted for non-payment and failed to adhere to the facility’s house rules and policies. (A1) confirmed to have received a payment from (ALW) in March 2024, which was deposited into the facility's account. (A1) reported that (R1) had health issues that required hospitalization in January 2024, and was hospitalized after being issued a 30-day Eviction Notice. (A1) claimed that (R1) never signed an Admissions Agreement. As a result, (R1) is not considered a resident at the facility. (A1) assumed that without an Admission Agreement, there is no valid contract with (R1). (A1) did not have an obligation to accept the resident back and the 30-day Notice was served. (A1) claimed (R1)’s belongings were picked up while the resident was still in the hospital. In (A1)'s opinion, (R1) needed a higher level of care but did not have a medical assessment from the hospital records to support the claim. (A1) agreed to provide a copy of the Eviction Notice issued to (R1) and a copy of the facsimile receipt sent to the (WHS) (CCL) Regional office to LPA Dabuet on 05/19/24.

On 05/18/24, between 03:35 pm – 4:4pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed staff #1 (S1) and residents #2-#3 (R2-R3). (R2-R3) claimed they did not know about (R1)’s residency before their placement at this facility. (S1) claimed to have no knowledge of the matter concerning (R1) as (S1) is a recent hire at the facility. ( R4) was unavailable for an interview and could not give a statement.

(LPA) Ernand Dabuet could not obtain additional statements related to the allegations in this complaint from (R1) due to unreturned calls.

According to internal records (dated: 01/17/24, 01/18/24, and 01/23) reviewed by (LPA) Dabuet, (A1) was informed of by (CCL) Associate Government Program Analyst (AGPA) Aileen Aguinaldo, it is the responsibility of the facility despite the 30-day Eviction Notice issue to (R1), and that (A1) agreed and will allow (R1) to return to the facility.

(Evaluation Report continues LIC 9099-C)


This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created on 05/19/24.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240124103329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
VISIT DATE: 05/19/2024
NARRATIVE
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The documents were sent by facsimile to (CCLD) with no confirmed receipt from (A1). The (WHS) (CCL) Regional Office had no records on file. The facility failed to follow up with (CCL) for approval as written in Title 22 Regulations Section 87224 Eviction Procedures. (A1) failed to follow up and contact the Department informing that a 30-day Notice was issued to (R1). It was determined the notice was not valid. (A1) failed to provide a copy of the notice to LPA Dabuet along with facsimile receipt. Based on interviews and record reviews, there is sufficient evidence to support the allegation mentioned above.

Based on the Department's observation and interviews, records reviews, and analysis, the preponderance of evidence standard has been met, therefore the allegation of “Staff abandoned resident at hospital" is Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Jan Allen Vernon De Jesus. The Rights were discussed with Nicol De Las Alas by telephone, and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report.


SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240124103329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87224(b)
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87224(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good csafety... mental and/or physical health or safety of others in the facility.ause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or
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Licensee is to review Title 22 Regulaiton Section 87244, and resubmit a written statement to CCL to indicate it was reviewed and understood. POC must be sent to LPA Dabuet at ernand.dabuet@dss.ca.gov by 05/31/24.
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This requirement is not met as evidenced by: Based on interviews and record reviews. The facility failed to properly inform CCLD of the 30-Day Notice of Eviction for (R1) and failed to provide evidence of notice submitted. The notice is not valid unless CCLD approves. This violation posed a potential health risk to residents in care.
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Type B
05/31/2024
Section Cited
CCR
87468.1(2)
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87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by
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Licensee will need to provide will adhere to Title 22 87468.1 and submit a written statement that to indicate it was reviewed and understood. Proof of correction must be sent to LPA by email at ernand.dabuet@dss.ca.gov by 05/31/24.
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Based on interviews and record reviews, the licensee did not comply with the section. The faciltiy failed to accept (R1) upon discharge from hospital. This violation 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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5