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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603457
Report Date: 12/19/2025
Date Signed: 12/19/2025 03:10:19 PM

Unsubstantiated


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
11/14/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251114111409
FACILITY NAME:AYANNA HOME CAREFACILITY NUMBER:
198603457
ADMINISTRATOR:MATE, KELVINFACILITY TYPE:
740
ADDRESS:5602 WHITEWOOD AVETELEPHONE:
(909) 351-6012
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:6CENSUS: 5DATE:
12/19/2025
UNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Caregiver Mitchell CastanedaTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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facility is not meeting resident’s needs.
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 Mitchell Castaneda who assisted with today’s visit. Administrator Elba Rodriguez was notified by telephone.

The investigation consisted of the following: During the initial visit conducted on 11/20/2025, LPA obtained copies of the following documents: Staff roster, resident roster, R1 physician report LIC 602, resident appraisal LIC 603A, identification and emergency information LIC 601, medical record progress notes, after visit summary notes, and requested plan of operation. LPA Gutierrez interviewed Administrator and did a tour of home LPA observed a sufficient supply of food and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On today’s visit LPA interviewed staff 1-staff 2 (S1-S2), residents 2 -residents 5 (R2-R6) and delivered findings. See LIC 9099C

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

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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-20251114111409
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: AYANNA HOME CARE
FACILITY NUMBER: 198603457
VISIT DATE: 12/19/2025
NARRATIVE
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In regard to the allegation “facility is not meeting resident’s needs”, it is alleged that R1 may need a higher level of care than what the facility could provide. During interviews with Administrator and staff three (3) out of three (3) stated that they believed that they could care for R1. Administrator stated that R1 was at the facility for less than three weeks in total and during that time enough care was provided. LPA was able to obtain documents stating that prior to admission to facility R1 was in VA hospital and did not come to facility till 10/17/2025. Facility obtained a LIC 602 physicians report that did not indicate any prohibited health conditions, on 10/22/2025 family took R1 to a doctor’s appointment for a checkup and no health concerns were reported, on 10/30/2025 family took R1 to emergency room where he stayed for two weeks, on 11/17/2025 R1 went back to hospital and did not return back to facility due to being transferred to a skilled nursing home. During interviews with residents four (4) out of five (5) residents stated facility staff take care of them. R4 stated that it is wonderful here.

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 Mitchell Castaneda.

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

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
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