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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320051
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:12:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20231220145901
FACILITY NAME:PEPPER TREE ASSISTED LIVINGFACILITY NUMBER:
198320051
ADMINISTRATOR:LUZVIMINDA BASA PARAISOFACILITY TYPE:
740
ADDRESS:2353 251ST STREETTELEPHONE:
(424) 250-9786
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 3DATE:
12/22/2023
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:MARHLYN SAPUGAYTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff are not addressing pest infestation at the facility.
Uncleared adult(s) are working at the facility.
INVESTIGATION FINDINGS:
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On 12/22/2023 at around 12:55 pm, LPA Lourdes Montoya conducted an initial 10-day complaint visit at this facility to investigate the above allegations. LPA met with Caregiver Emma Fernandez. LPA explained the purpose of today's visit. Administrator Marhlyn Sapugay arrived shortly after and assisted LPA Montoya with the visit.

The investigations consisted of the following: LPA toured the facility with Administrator Marhlyn Sapugay. LPA obtained and reviewed the staff roster & resident roster, timesheets, and other pertinent records. LPA conducted interviews with two staff (S1 and S2). LPA observed two residents (R1 and R2) present and both residents (R1 and R2) were sleeping. LPA was unable to obtain statements from R1 and R2.

REPORT CONTINUED IN LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
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 11-AS-20231220145901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051
VISIT DATE: 12/22/2023
NARRATIVE
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Investigations revealed the following:

Allegation: Staff are not addressing pest infestation at the facility.

SOC 341 indicates “The facility is cockroach infested”.

It is alleged that staff are not addressing pest infestation at the facility. On 12/22/2023 at 1:00 pm, LPA Montoya toured the facility. LPA observed two insect traps in the kitchen on the floor.

From 1:20 pm – 1:45 pm, LPA Montoya interviewed two staff (S1-S2). Based on interview with S1, it was revealed that the facility has pests and licensee hired Orkin to provide pest control services to the facility. S2 stated Orkin began pest control services a few months ago and continued to provide treatments to inside and outside areas of the facility every other two weeks.

From 1:50 pm – 2:15 pm, LPA Montoya reviewed the Orkin service reports. Based on records review, the facility has a pest control service agreement with Orkin dated 8/12/2023. LPA observed Orkin serviced the facility on August 12, September 19, October 11, 16, 20, 30, November 6, 10, 30 and December 16 of 2023. Service reports show Orkin inspected for pest activity and treated in common areas as necessary, both interior and exterior grounds. Based on records review, interviews and observations, the facility has timely taken the necessary actions to combat the pest infestation and therefore there is not enough evidence to prove the above allegation.

Allegation: Uncleared adult(s) are working at the facility.

SOC 341 indicates “The facility has been hiring undocumented caregiver with no permission to work”.

It is alleged that “Uncleared adult(s) are working at the facility”. On 12/22/2023 from 1:50 pm – 2:15 pm, LPA Montoya conducted interviews with S1 and S2. Both S1 and S2 stated there are two regular caregivers (S2-S3), three caregivers/relievers (S4-S6), and the administrator (S1) working at this facility and .

REPORT CONTINUED IN LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20231220145901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051
VISIT DATE: 12/22/2023
NARRATIVE
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From 2:20 pm – 2:30 pm, LPA reviewed the staff roster (LIC 501), Personnel Summary and time sheets. Based on LPA’s records review, all staff (S1-S6) working at this facility have California background clearances. Based on records review, interviews and observations, there is not enough evidence to prove the above allegation.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; Therefore, the allegations, "Staff are not addressing pest infestation at the facility” and “Uncleared adult(s) are working at the facility” are found to be UNSUBSTANTIATED.

No deficiencies were cited during this visit.

An exit interview was conducted with Administrator Marhlyn Sapugay and a copy of the report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3