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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005856
Report Date: 01/25/2023
Date Signed: 01/25/2023 03:17:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
10/18/2022 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221018121747
FACILITY NAME:HAVEN FOR MOM & DAD 1FACILITY NUMBER:
306005856
ADMINISTRATOR:CALMA, RHODAFACILITY TYPE:
740
ADDRESS:1221 SIERRA VISTA DRTELEPHONE:
(562) 228-4439
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 5DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Administrator, Rhoda CalmaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
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9
Resident was denied visitation.
INVESTIGATION FINDINGS:
1
2
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5
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9
10
11
12
13
Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to deliver findings on the complaint investigation. LPA met with and discussed the purpose of the visit with Administrator, Rhoda Calma.

The department investigated the above allegation and the investigation consisted of interviews, observations, and documentation. Based on the interviews conducted, the investigation revealed that resident 1 (R1) received visitors in the facility. Visitors were granted entry after completing Covid 19 screening. Visitors were directed to visit in the outside patio area designated for visitation. During Visitation, a family member was contacted regarding visitors for R1 at family’s request. The family member arrived at facility shortly after asking visitors to leave. While conducting a visit to the facility on 1/17/23 R1 was conversant and was able to express they wanted family to visit. Interviews conducted with staff revealed that three out of three staff state they have never denied resident’s visitation.

CONTINUED ON 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 1
Control Number 22-AS-20221018121747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HAVEN FOR MOM & DAD 1
FACILITY NUMBER: 306005856
VISIT DATE: 01/25/2023
NARRATIVE
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 Interviews with family members revealed that Four out of Six family members expressed no issues with facility visitation, while remaining two of six family members claim their other family member is asking to be notified while R1 is being visited at facility.

Due to the conflicting information obtained from various family members, staff and R1, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation that resident was denied visitation is deemed UNSUBSTANTIATED.

LPA Tirre conducted exit interview with Administrator Calma and a copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 1 of 3