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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603021
Report Date: 12/11/2025
Date Signed: 12/11/2025 12:38:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/27/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251027133520
FACILITY NAME:FAMILY HOME LLCFACILITY NUMBER:
198603021
ADMINISTRATOR:VILLALVA, JOEL HFACILITY TYPE:
740
ADDRESS:1629 CALLE CIERVOTELEPHONE:
(626) 354-0265
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Arlene Dulay CaregiverTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff working do not have criminal record clearance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Caregiver Arlene Dulay and explained the reason for today’s visit. House Manager Shelly Yamashiro was notified by telephone.

The investigation consisted of the following: During the initial visit conducted on 11/04/2025 LPA Gutierrez interviewed S1. LPA obtained copies of the following documents: staff roster, resident roster and toured the garage. On today’s visit LPA Gutierrez interviewed staff 2-staff 3 (S2-S3) in person, staff 4 (S4) over telephone, residents 1-residents 4 (R1-R4), and delivered findings.

See 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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 5
Control Number 28-AS-20251027133520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY HOME LLC
FACILITY NUMBER: 198603021
VISIT DATE: 12/11/2025
NARRATIVE
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In regard to the allegation “Staff working do not have criminal record clearance”, it is alleged that S5 was not fingerprint cleared. During interviews with staff one (1) out of four (4) S1 stated that they thought S5 was cleared and was unaware they were pending background clearance. During interviews with residents four (4) out of four (4) residents couldn’t remember S5. During record review LPA discovered that S5 was pending background check clearance and not cleared.

Immediate Civil Penalties assessed during this visit.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Caregiver Arlene Dulay.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20251027133520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAMILY HOME LLC
FACILITY NUMBER: 198603021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2025
Section Cited
CCR
87355(e)(2)
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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Obtain a California clearance or a criminal record exemption as required by the Department

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Licensee will insure al staff is finger print cleared prior to working with residents. S5 no longer works at the facility.
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This requirement was not met as evidenced by: S5 did not have record of criminal clearance transfer. This poses an immediate risk to the health, safety, or personal rights of 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: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/27/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251027133520

FACILITY NAME:FAMILY HOME LLCFACILITY NUMBER:
198603021
ADMINISTRATOR:VILLALVA, JOEL HFACILITY TYPE:
740
ADDRESS:1629 CALLE CIERVOTELEPHONE:
(626) 354-0265
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Arlene Dulay CaregiverTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
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9
Staff were drinking alcohol in the facility.
Staff were using drugs in the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Caregiver Arlene Dulay and explained the reason for today’s visit. House Manager Shelly Yamashiro was notified by telephone.

The investigation consisted of the following: During the initial visit conducted on 11/04/2025 LPA Gutierrez interviewed S1. LPA obtained copies of the following documents: staff roster, resident roster and toured the garage. On today’s visit LPA Gutierrez interviewed staff 2-staff 3 (S2-S3) in person, staff 4 (S4) over telephone, residents 1-residents 4 (R1-R4), and delivered findings.

See 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20251027133520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY HOME LLC
FACILITY NUMBER: 198603021
VISIT DATE: 12/11/2025
NARRATIVE
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In regard to the allegation “Staff were drinking alcohol in the facility”, it is alleged that staff were drinking alcohol in the garage. During interviews with staff four (4) out of four (4) stated that they have never witnessed any staff drinking alcohol at the facility. During interviews with residents four (4) out of four (4) residents stated that they have never seen staff drink alcohol at the facility. During pre investigation LPA obtained a picture of alcohol in a drawer, however LPA cannot confirm where and when picture was taken. LPA toured garage at time of visit and did not observe any alcohol.

In regard to the allegation” Staff were using drugs in the facility”, it is alleged that staff is smoking marijuana in the garage. During interviews with staff four (4) out of four (4) staff stated that they never witnessed staff doing drugs at facility. S1 stated that it was reported to him/her about possible drug use but S5 left facility and never returned. During interviews with residents four (4) out of four (4) residents stated they have not witnessed staff doing drugs at the facility. LPA obtained a picture of a pipe in a drawer however LPA cannot confirm where and when picture was taken. LPA toured garage at time of visit and did not observe any drugs.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Caregiver Arlene Dulay.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5