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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005500
Report Date: 05/01/2023
Date Signed: 05/01/2023 02:31:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2023 and conducted by Evaluator Jerome Haley
COMPLAINT CONTROL NUMBER: 22-AS-20230427090922
FACILITY NAME:CARE JULIET 1FACILITY NUMBER:
306005500
ADMINISTRATOR:DEL ROSARIO, LESTERFACILITY TYPE:
740
ADDRESS:479 S WELLINGTON RDTELEPHONE:
(209) 914-1153
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 6DATE:
05/01/2023
UNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Administrator John Del RosarioTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Untrained staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced initial 10-day visit regarding the complaint allegation listed above. LPA identified himself and explained the reason for the visit with staff who called Administraotr (AD) John Del Rosario via telephone who arrived a short time later. Before interviewing residents and staff to gather details, LPA Haley toured the interior and exterior of the facility with Staff 1 (S1).

Regarding the allegations, “Untrained staff” The investigation revealed the following:

During the initial visit May 1, 2023, LPA Haley toured the facility and conducted interviewes with the Administrator, 2 staff and 4 residents. During the interview with Staff 2 (S2), S2 stated he was new and he has not received/started any training yet. S2 did mention he's only shadowing right now and explained what he's learned. After the interview, LPA Haley asked AD Del Rosario about training for S2 and asked to review training records for S2. There were no trining records available for S2.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
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 22-AS-20230427090922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE JULIET 1
FACILITY NUMBER: 306005500
VISIT DATE: 05/01/2023
NARRATIVE
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There was only a live scan and personnel record (LIC501) available for review. AD Del Rosario stated S2 has only been shadowing since he started. AD Del Rosario was unclear of the status of S2s training because AD Del Rosario had to asked S2 did he begin online training, while LPA Haley was present and S2 said "No."
LPA Haley asked AD Del Rosario has the shadowing S2 has done been documented? Is the on the job training (shadowing) being documented? LPA Haley also asked are there any descriptions of the shadow training S2 has received? AD Del Rosario was no. Nothing has been documented regarding the training for S2.

Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit interview was conducted and a copy of this report, LIC9099D, and appeal rights were provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230427090922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARE JULIET 1
FACILITY NUMBER: 306005500
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2023
Section Cited
CCR
87411(c)(6)
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Personnel Requirements - General
The licensee shall maintain documentation pertaining to staff training... as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer,... covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.
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Administrator will read and review Regulation 87411 and send LPA Haley an email confirming the regulation has been read and understood. Administrator Del Rroasrio will also email a breakdown of the shadow training completed by S2, who S2 shadowded, and how much time S2 was trained on each topic. AD Del Rosario will also have Staff 2 start the required 20 hours of online training and email LPA proof online training has started with an estimated complation date. POC due date is Wednesday, May 3, 2023 at 12 noon.
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This requirement is not being met as evidenced by interview confirmation with the facility administrator and staff file review. This poses a health and safety risk to residents 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: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3