<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603553
Report Date: 01/18/2024
Date Signed: 01/18/2024 09:58:16 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/11/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240111113802
FACILITY NAME:TIMERS RESIDENTIAL CAREFACILITY NUMBER:
198603553
ADMINISTRATOR:WILLIAMS, SHAUNDAFACILITY TYPE:
740
ADDRESS:452 PEMBROOK AVENUETELEPHONE:
(424) 457-9771
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY:6CENSUS: 3DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shaunda WilliamsTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are illegally evicting resident from the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced visit to investigate the above
allegation. LPA met with Shaunda Williams and discussed the purpose of today’s visit.

During this investigation, LPA obtained a copy of the staff and resident rosters, reviewed file for R-1 and obtained relevant documentation and interviewed Shaunda Williams/S-1. LPA was unable to interview R-1 as R-1 was taken to the hospital and is unavailable for an interview.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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 3
Control Number 28-AS-20240111113802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TIMERS RESIDENTIAL CARE
FACILITY NUMBER: 198603553
VISIT DATE: 01/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff are illegally evicting resident from the facility. It is alleged that staff illegally evicted R-1 from this facility. The latest 30-day eviction notice allegedly provided to R-1 was sent to LPA via e-mail on 01/05/24 which was missing required elements as per Health and Safety Code 1569.683. R-1’s 30-day eviction notice was missing the correct phone number for Department of Social Services-Community Care Licensing, reasons relied upon the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons and information about resources to assist the resident in identifying alternative housing and care options, including public and private referral services and case management organizations. On 01/10/24, LPA sent an email to Shaunda Williams inquiring on numerous eviction notices (revisions) that were sent to LPA via e-mail pertaining to R-1 as the 30-day eviction notice was incomplete. As of today, LPA has not received an updated 30-day eviction notice for R-1. Allegation is corroborated.

Based on interview conducted and emails received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited. Refer to LIC 9099D. A copy of the Health & Safety Code 1569.683 was provided to Ms. Williams/Administrator.

An exit interview was held. A copy of this report along with appeal rights were provided to Shaunda Williams.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240111113802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TIMERS RESIDENTIAL CARE
FACILITY NUMBER: 198603553
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
HSC
1569.683
1
2
3
4
5
6
7
Eviction notices; reasons for eviction contents; service. (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with
1
2
3
4
5
6
7
Administrator to rescind the most recent eviction notice as it is missing required elements (as noted on this report) and reissue a new 30-day eviction notice.
8
9
10
11
12
13
14
specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This standard is not met as evidence by: R-1 was provided with an incomplete 30-day eviction notice. The details of the missing elements are noted on this report.
8
9
10
11
12
13
14
Administrator to provide a copy of the revised eviction notice and proof of delivery to R-1 to LPA by POC due date.

Note: A copy of the Health & Safety Code 1569.683 was provided to Ms. Williams/Administrator.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3