197610333-5-19-2024-31-AS-JHAD-D5K23R-20240523170247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610333
Report Date: 05/18/2024
Date Signed: 05/19/2024 04:32:20 PM

Unsubstantiated

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
07/03/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230703082026

FACILITY NAME:	HUMBLE HAVEN RCFE IV		FACILITY NUMBER:	197610333
ADMINISTRATOR:	DE LAS ALAS, NICOLE		FACILITY TYPE:	740
ADDRESS:	4036 TOURNAMENT DRIVE		TELEPHONE:	(707) 688-5606
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 6	DATE:	05/18/2024
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Jasmin & Jennifer Bihasa		TIME COMPLETED:	10:21 AM

ALLEGATION(S):

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Staff does not provide adequate food service to residents in care.

INVESTIGATION FINDINGS:

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On 05/18/24, Licensing Program Analyst (LPA) Ernand Dabuet made subsequent unannounced visit to this facility and was greeted by caregiver staff #1 Jasmin Bihasa. LPA Dabuet contacted the administrator Nicole De Las Alas who was not available for this visit. LPA explained the purpose for 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 who met with Albert Gonzalez. (LPA) requested copies of files for resident #1 (R1’s) ID and Emergency Information, Admissions Agreement (dated: 08/03/23), Physicians Report LIC 602A (dated: 07/14/23), Preplacement Appraisal Information LIC 603 (dated: 12/20/21), Register of Facility Residents LIC 9020 (dated: 09/10/23) and Facility Roster, Facility Weekly Menu, and Photos Food Supply (dated: 05/17/24). A review of residents #2-#6 (R2-R6)’s service files. Interviews conducted with residents #1-#6 (R1-R6), staff #1-#3 (S1-S3), and witness #1-#3 (W1-W3). A tour of the facility was performed.
(Evaluaiton Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

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 3

Control Number 31-AS-20230703082026

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 IV	FACILITY NUMBER: 197610333
	VISIT DATE: 05/18/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff does not provide adequate food service to residents in care.

The details of the complaint reported the facility staff does not provide adequate food service to residents in care. The complainant reported resident#1 (R1) is not being fed lunch and healthy and sufficient food. Furthermore, the facility is also not following the meal regulations when dinner time is too early and no snacks.

The Department conducted an inspection visit on 07/06/23, 05/17/24, and 05/18/24 and observed the facility is following Title 22 Section 87555 General Food Service Requirements. The Department observed food supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The food supply included milk products, meat, vegetables, fruits, bread, cereals, juices, and desserts. A weekly menu was posted and made available for review for residents.

On 05/17/24, between 11:16 am – 11:31 pm, the Department interviewed resident #1 (R1). (R1) confirmed the facility served three meals daily with snacks. (R1) stated the facility provided adequate food portions and a variety. (R1) stated (R1) preferred not having in-between meal snacks as meal portions are sufficient. (R1) claimed (R1) had to be mindful of gaining weight. (R1) reported not having issues with meals being serviced at breakfast at 8 am, lunch at noon, and dinner at 6 pm.

On 05/17/24, between 11:32 am – 11:55 am, the Department interviewed (5) out of (5) residents #2 - #6 (R2-R6) who were complimentary of staff. (R2-R6) reported that they were provided with three meals and snacks and that the portion sizes were adequate. (R2-R6) reported the meals were satisfactory and were served at proper mealtimes.

On 05/17/24, between 11:56 am – 12:21 pm, the Department interviewed (3) out of (3) staff #1 - #3 (S1-S3) reported that groceries are restocked every week.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230703082026

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 IV	FACILITY NUMBER: 197610333
	VISIT DATE: 05/18/2024

NARRATIVE

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(S1-S3) reported following the weekly menu plan and portion sizes. The services of meals as indicated on the plan with breakfast 8:00 am – 9:00 am, lunch 12:00 pm – 01:00 pm, and dinner 5:00 pm – 6:00 pm are followed. In between refreshments are provided to all residents in care according to (S1-S3).

On 05/17/24, between 02:32 pm and 03:55 pm, the Department interviewed (3) out of (3) witnesses #1-#3 (W1-W3).

Two (2) out of (3) three verified having no issues with the facility's food meals or services. (W1) cited being very pleased with the management and staff at this facility, and the care and services provided were excellent.

As a result of the Department reviewing (R1-R6)'s Physician Report LIC 602A, it revealed that (3) out of (6) are not required to be on any dietary restrictions, while the other three are on a mechanical soft diet. Based on the gathered information, the allegation mentioned above cannot be supported.

Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. 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.

No deficiencies were cited.

An exit interview is conducted with Jasmin Bihasa and a copy of the report is provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC9099 (FAS) - (06/04)

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