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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320397
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:20:08 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
10/24/2024 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241024194808
FACILITY NAME:DIVINE LIFE GUEST HOMEFACILITY NUMBER:
198320397
ADMINISTRATOR:ROSALDO, RODRIGOFACILITY TYPE:
740
ADDRESS:1711 W. 243RD ST.TELEPHONE:
(310) 310-1851
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 5DATE:
11/15/2024
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Alvin Geniza - Care Giver / Lead StaffTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff restrained resident in care.
Staff yelled at resident in care.
INVESTIGATION FINDINGS:
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On 11/15/2024, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint visit at this facility and was greeted by the Administrator Rosaldo Rodrigo. LPA explained the purpose of the visit is to deliver findings for the allegations listed above and was allowed entrance into the facility.

The investigation consisted of the following:

On 11/01/2024 LPA Watson toured the facility, reviewed records and interviewed staff and residents. LPA interviewed staff #1-#6 (S1-S6) and interviewed residents #1-#4 (R1-R4). LPA Watson requested, received, and reviewed Physician's Reports, Appraisal Needs and Services, Staff schedule for staff (S1-S6) and Residents Roster, for residents (R1-R4). The department toured the buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats.

CONTINUED ON LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
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 11-AS-20241024194808
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: DIVINE LIFE GUEST HOME
FACILITY NUMBER: 198320397
VISIT DATE: 11/15/2024
NARRATIVE
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The investigation revealed the following:

Allegation: Staff restrained resident in care

On 11/01/2024 LPA Troy Watson interviewed staff #1-#6 (S1-S6). The question asked of the staff was, have you ever restrained any of the residents that live at the facility? 6 out of 6 staff interviewed answered no. On 11/01/2024 LPA interviewed residents #1-#4 (R1-R4). Of those interviewed 4 out of 4 residents were asked if they had been put in restraints? 4 out 4 residents replied to no.

Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. 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 allegations are Unsubstantiated.

Allegation: Staff yelled at resident in care

On 11/01/2024 LPA Troy Watson interviewed staff #1-#6 (S1-S6). The question asked of the staff was, have you yelled at anyone of the residents in this facility? 6 out of 6 staff interviewed answered no. On 11/01/2024 LPA interviewed residents #1-#4 (R1-R4)4 out of 4 residents were interviewed and asked if anyone has yelled at them? 4 out of 4 residents replied to no.

Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. 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 allegations are Unsubstantiated.

An exit interview was conducted with Administrator Rosaldo Rodrigo, and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2