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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700225
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:29:34 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20221110163839
FACILITY NAME:MONA LIZAFACILITY NUMBER:
392700225
ADMINISTRATOR:SALEH, MOTHANNAFACILITY TYPE:
740
ADDRESS:1552 MIDDLE FIELD AVETELEPHONE:
(209) 910-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 5DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:Mothanna Saleh via phoneTIME COMPLETED:
03:51 PM
ALLEGATION(S):
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Resident eloped over night due to lack of supervision
INVESTIGATION FINDINGS:
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On 11-17-22 at 2:49pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the allegation noted above. LPA was greeted by staff1 (S1) and spoke with Acting Administrator (S2). LPA also spoke with Administrator Mothanna Saleh via phone and explained the purpose of the visit. LPA interviewed Administrator, acting administrator and S1. LPA also reviewed physician's report for R1. Additionally, LPA reviewed emergency response report for R1. Based on interviews and record reviews, it was determined that R1 eloped from facility on 11-9-22 and facility staff was unable to locate R1 between approximately 6:00am and 7:00am. It was further revealed that facility staff was unaware of R1's whereabouts during this time period until staff called 9-1-1 and learned of R1's admission to local hospital. Based on interviews and record reviews, it is determined that R1 was without staff supervision due to an absence without leave (AWOL) episode. As a result, this allegation is SUBSTANTIATED. Citation is issued today under Title 22, Health and Safety Code, Chapter 3.2 and noted on LIC 9099D. An immediate civil penalty of $500 is issued in addition to citation. An exit interview was conducted with S1 and a copy of this report was left with S1. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
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 2
Control Number 27-AS-20221110163839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MONA LIZA
FACILITY NUMBER: 392700225
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
HSC
1569.312(d)
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Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts...This requirement was not met as evidenced by:
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Licensee will read regulation 1569.312 and submit a signed declaration of understanding to LPA by POC due date

Licensee will complete staff training on elopement procedures and proper supervision of residents. Licensee to submit training date to LPA by POC due date. Training shall be completed no later than 2 weeks after date of citation issuance with proof of completion sent to LPA.
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Based on interview and record review, R1 eloped from facility on 11-9-22 and staff was unaware of R1's whereabouts for approximately 1 hour resulting in an absence of supervision. This posed an immediate health and safety risk to resident in care. An immediate civil penalty is assessed in addition to citation issued.
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Licensee will submit a plan ensuring staff knowledge of resident whereabout to LPA by POC due date.
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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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
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