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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336424160
Report Date: 04/11/2022
Date Signed: 04/11/2022 10:24:16 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2022 and conducted by Evaluator Jesse Gardner
COMPLAINT CONTROL NUMBER: 18-AS-20220408133815
FACILITY NAME:HAPPY NEST IIIFACILITY NUMBER:
336424160
ADMINISTRATOR:CAMUA, GEORGEFACILITY TYPE:
740
ADDRESS:3020 E. VISTA CHINOTELEPHONE:
(760) 322-8528
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:6CENSUS: 6DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caretaker Michelle HashimotoTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Faciltiy has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unanounced in order to investigate the above allegation. LPA identified himself and discussed the purpose of the visit and the elements of the allegation with Caretaker Michelle Hashimoto. LPA then toured the facility.

According to the statement provided in the allegation, LPA inspected the drawer where the facility keeps silverware and immediately saw a roach walking through the drawer, and quickly out of sight. LPA also noticed multiple roach carcasses, in which pictures were obtained. Administrator Claire Itchon arrived at the facility.

Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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 18-AS-20220408133815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HAPPY NEST III
FACILITY NUMBER: 336424160
VISIT DATE: 04/11/2022
NARRATIVE
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Due to the located evidence of bugs, LPA substantiated the allegation. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Thus a Type B citation was issued per Title 22 Division 6 Chapter 8 Article 10 87555(b)(27) General Food Service Requirements.

An exit interview was conducted with Administrator Claire Itchon, in which this report was discussed with and a copy of this report along with copies of the LIC9099-C, LIC9099-D, as well as Appeal Rights were provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220408133815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HAPPY NEST III
FACILITY NUMBER: 336424160
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited
CCR
87555(b)(27)
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GENERAL FOOD SERVICE REQUIREMENTS: (b) The following..shall apply:(27)All kitchen..shall be..clean and free..of insects.. This was not met as evidenced by:
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Licensee agrees to provide an updated cleaning plan, and proof of continued pest control service, and provide LPA proof of such via email by the POC date.
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Based on LPA's observation, Licensee did not adhere to the regulation by the evidence found of insects. This poses a potential health and safety and personal rights 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: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3