<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700225
Report Date: 03/18/2024
Date Signed: 03/18/2024 01:26:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240205150133
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: 6DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Vicky SantillanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with scheduling medical appointments
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/18/2024, LPA Johnson made an unannounced visit to deliver findings for the above allegations. LPA met with Vicky Santillan

Allegation: Staff did not assist resident with scheduling medical appointments. Based on records reviewed the facility did not make appointments for R2 to get an updated physician's report. The department also interviewed R1 and confirmed that the facility has not schedule or assisted to schedule an appointment to have R1's see the optometrist.

Continued.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240205150133

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: 6DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Vicky SantillanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal items
Staff does not provide daily activities for resident
Staff do not provide clean laundry for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Allegation: Staff did not safeguard resident's personal items. Based on records reviewed, interviews with the admimistartor and R1. The facility did completed the inventory sheet for R1, who moved into the facility on 1/1/2024 and the information includes all items listed as of the department's review today. The personal item that was the primary focus of the lost item was a cell phone that was taken away from R1 while R1 was at the emergency room. This item was not part of the inventory for R1 when she moved into this facility and therefore is not missing from the inventory items. The department was unable to confirm that any additional items not listed on the move in inventory sheet were missing or misplaced.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240205150133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONA LIZA
FACILITY NUMBER: 392700225
VISIT DATE: 03/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff does not provide daily activities for resident. Based on interviews and records reviewed the facility has established a calendar of activities and daily items are listed that the facility has determined to be happening at the time, however the activities happening are alternatives to what is listed. The residents interviewed confirmed that they are not interested in the items listed but would prefer watching television. The residents interviewed confirm that if they had a chose they would not go out. They prefer staying home.

Allegation: Staff do not provide clean laundry for resident. Based on interviews with the residents and staff, the facility provide laundry service for all residents, however, R1 does not want anybody touching her items. R1 had a bad experience at another facility and stated that someone would steal clothing when it was wash day. The facility attempted to reassure R1 that this would not happen at this facility. R1 refused to allow staff to wash clothes unless R1 was there to make sure the washed items were not stolen.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240205150133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONA LIZA
FACILITY NUMBER: 392700225
VISIT DATE: 03/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
As a result, these allegations are SUBSTANTIATED. Citation is issued today under Title 22, Health and Safety Code, Chapter 3.2 and noted on LIC 9099D. Appeal rights provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240205150133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MONA LIZA
FACILITY NUMBER: 392700225
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2024
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
Incidental Medical and Dental Care:The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by
1
2
3
4
5
6
7
Facility will schedule an appointment for resident to be assessed by R2's physician an R1 will have anappointment scheduled for the eye doctor.
8
9
10
11
12
13
14
8
9
10
11
12
13
14
 Facility will provide a written statement to the department indicating the steps the facility will take to ensure the deficiency does not reoccur by POC date 3/25/24
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5