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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005500
Report Date: 07/21/2023
Date Signed: 07/21/2023 01:24:19 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
07/14/2023 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230714131232
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:
07/21/2023
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Julieta Cervania- House ManagerTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility has fire hazards.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an uannounced visit for the purpose to conduct a complaint investigation into the above allegation. LPA was greeted and granted entry by House Manager (HM) Juileta Cervania and stated the purpose of the visit. LPA also met with Caregivers Janella Cervania and Bayani Villarosa. LPA spoke to Administrator (Admin) Lester Del Rosario via a telephone call approximately 9:55am and received consent for HM to sign the report on his behalf. During the course of the investigation, LPA observed six residents in care, toured the physical plant including the patio, interviewed residents/staff, and obtained pertinent resident records. The following are the findings which involved observations, record review, and interviews:

It was alleged that facility has fire hazards. LPA along with HM Cervania observed the presence of the Additional Dwelling Unit (ADU) located in the patio area and observed that it was being occupied by Caregiver #2 (C2) as their primary residence.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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-20230714131232
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: 07/21/2023
NARRATIVE
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The Administrator corroborated that the addition of the ADU was not cleared by the Orange County Fire Department and is a suspected fire hazard that may affect the health and safety to the residents.

Therefore, based on the observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the allegation: facility has fire hazards is deemed SUBSTANTIATED as per Title 22 of the California Code of Regulations, Division 6, Chapter 8. A citation is being issued on the attached LIC9099D.

An exit interview was conducted with House Manager Julieta Cervania, and a copy of this report including the LIC 9099C, LIC9099D, and the appeal rights were provided during today's visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230714131232
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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2023
Section Cited
CCR
87305(b)
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87305 Alterations to Existing Building or New Facilities (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.
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Administrator to submit a LIC200 and updated outdoor facility sketch to LPA via email by POC due date.
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This requirement was not met as evidenced by: Based on LPA's observations and interviews, Administrator corroborated that the dwelling unit was not cleared by the fire department which poses a potential Health, Safety, or Personal Rights risk to 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: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3