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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604273
Report Date: 01/09/2025
Date Signed: 04/04/2025 12:20:31 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2021 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20210721101943
FACILITY NAME:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR:FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Teresita Duclayan, Care GiverTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Licensee did not provide supporting care to meet the needs of the resident.
Licensee did not safeguard resident's personal belonging.
INVESTIGATION FINDINGS:
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**This is an amended report***
Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit with Care GIver Teresita Duclayan. LPA Rodgers called Licensee Myrna Arceleo upon arrival to inform them of LPA Rodgers' presence and purpose in the facility, but they decided not to join the visit.

On July 21, 2021, Community Care Licensing (CCL) received a complaint alleging that the LIcensee did not provide supporting care to meet the needs of the resident and the licensee did not safeguard the resident's personal belongings. More specifically, the facility staff did not follow the orders given by the home health service provider regarding Resident #1 (R1), such as food service and turning R1 every two hours. Additionally, the facility staff kept the remote control to R1's personal TV.The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and a records review. (Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
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 2
Control Number 08-AS-20210721101943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA MAHAL
FACILITY NUMBER: 374604273
VISIT DATE: 01/09/2025
NARRATIVE
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****this is an amended report****
(Continued on 9099-C)
Regarding the allegation that the licensee did not provide care to meet the needs of the R1. All staff interviews acknowledge issues with being short-staffed, but most do not believe it directly caused resident needs to go unmet. Interviews with both Licensee and staff and in July of 2021 state R1's needs were being met. Interviews with R1's responsible party and Licensee reveal home health care was providing only OT (Occupational Therapy) and PT (Physical Therapy) to R1. R1's responsible party's email states that verbal orders were given by home health care to the facility to provide a high-protein diet to R1. Licensee response to interview questions in July of 2021 indicate that meal plans are provided to staff with a variety of options and the facility provides balanced meals.
Licensee's response to interview questions also reveals R1's responsible party asked for R1 to be turned every 2 hours, not home health care. Although it was alleged that Licensee staff did not meet the needs of R1 Interviews and records reviews were unable to affirm that the facility staff did not follow the orders given by the home health service provider.

Regarding the allegation that licensee did not safeguard residents personally belongs, specially the remote control for a TV. Licensee response to interview questions in July 2021 indicate Licensee owned TV equipment, including the remote control, therefore resident did not own personal equipment in question. Interviews and record reviews were unable to affirm that the Licensee did not return all personal belongings to R1 upon departure from facility. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]

Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED.

An exit interview was conducted over the phone with Licensee Arcelao and Care Giver Teresita Duelayan to whom a copy of this report was reviewed and provided. Their signature below confirms receipt of these documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2