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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600141
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:51:54 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/07/2025 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250107092140
FACILITY NAME:HOLY HILL INC./CARFAX HOMEFACILITY NUMBER:
198600141
ADMINISTRATOR:FRANCISCO, ROBERTFACILITY TYPE:
740
ADDRESS:13831 CARFAX AVETELEPHONE:
(562) 867-3279
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:6CENSUS: 4DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Robert FranciscoTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Resident sustained unexplained bruising.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with Administrator Robert Francisco and the purspose of the visit was discussed.

During todays visit, LPA interviewed residents #1-#4 (R1-R4) and Staff #1-#3 (S1-S3). LPA conducted a health and safety check of the home, LPA reviewed and collected documents from R1's file related to the investigation. The investigation revealed the following:

In regards to the allegation "Resident sustained unexplained bruising", it is alleged that R1 had multiple unexplainable bruises on their body. (3) of (3) Staff interviewed denied the allegation. (4) of (4) Clients interviewed could not corroborate the allegation....

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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 2
Control Number 28-AS-20250107092140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY HILL INC./CARFAX HOME
FACILITY NUMBER: 198600141
VISIT DATE: 01/14/2025
NARRATIVE
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 Interviews show that R1 has an underlying health condition as well as a combination of medications that may lead to bruising easily so staff do body checks for R1. Staff stated any observations of bruises would be noted in the facilities communication logs as well. On 12/28/24 facility staff noticed bruising on R1's face and arm. R1 was unable to explain the bruising and staff had not observed any falls or accidents; therefore, resident was transported to the hospital for evaluation. Resident returned the same day with summary that the bruising may have been a result of their health condition. R1 interview was attempted but R1 was unable to respond to questions from LPA. Residents interviewed stated they have no issues or concerns and they feel safe in the facility. LPA observed various notes in R1's file, one from a nurse visit and one from the primary physicians stating that resident bruising to be normal/common/easily bruised due to their health condition and medication list. LPA observed the facilities communication log confirming that staff conducted a check on R1 and observed the bruising. LPA did not observe any immediate health and safety concerns during the visit. Based on file reviews, observation and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

An exit interview was conducted, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2