191222631-9-21-2022-28-AS-RORN-CJHUY7-20220922155929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191222631
Report Date: 09/21/2022
Date Signed: 09/21/2022 12:30:45 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2022 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220609100709

FACILITY NAME:	NELVILLE GUEST HOME		FACILITY NUMBER:	191222631
ADMINISTRATOR:	HERMINIA DELACRUZ		FACILITY TYPE:	735
ADDRESS:	2005 E. ORANGE GROVE BLVD.		TELEPHONE:	(626) 791-1170
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	6	CENSUS: 5	DATE:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Hermania De La Cruz		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Client hit another client while in care

INVESTIGATION FINDINGS:

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The purpose of this revised Complaint Investigation Report is to change the findings of the above allegation. On 06/14/22 LPA Wong delivered a final complaint investigation report to the administrator with unsubstantiated finding for all the above allegation. After completing the complaint investigation, LPA Wong received additional information which changed the finding.

On today's date, Licensing Programa Aanlyst (LPA) Christine Wong conducted a subsequent complaint visit and met with Staff Baola Ruiz and explained the purpose of the visit. Shortly after, the administrator Hemania De La Cruz arrived.

The investigation consisted of the following: LPA Wong and Pena both Interviewed the administrator, two staff (S1-S2), two clients (C4-C5) and attempted to interview three clients (C1-C3). LPAs also reviewed C1's documents include C1's face sheet, Pre-appraisal, Needs and Service Plan and Individual Program Plan (IPP). (See LIC 9099C for continuation)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220609100709

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NELVILLE GUEST HOME	FACILITY NUMBER: 191222631
	VISIT DATE: 09/21/2022

NARRATIVE

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The investigation revealed of the following: In regard to the allegation of “Client hit another client while in care.” LPA interviewed staff and reported C1 just moved to the above facility for three months and C1 is still adjusting at the above home. C1 used to live with the family and he can get whatever he wants. The incident was happened during lunch time, C1 was obsessed with food but limited and selective food choices, while the staff was preparing C1's lunch. He grabbed another client food and throw it away. Then C1 went to C2 who was sitting on the sofa and hit his shoulder twice with unknown reason. The staff immediately went and talked to C1 and asked him to calm down and redirect him and then C1 hit himself on his head too. Administrator reported there's no injury for C2 and does not need any medical attention. LPA interviewed clients and reported C1 also hit other clients in the facility, although staff did redirect C1 immediately.

Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22) cited on the attached 9099 D.

Exit interview conducted and the copy of the report and appeal right was provided to Administrator Hemania De La Cruz

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220609100709

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NELVILLE GUEST HOME	FACILITY NUMBER: 191222631
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/22/2022 Section Cited ILS 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Right (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons	1 2 3 4 5 6 7	The facility Administrator shall have an in- service training with all staff on Personal Rights. The facility Administrator will develop a plan that will ensure C1 will not hit another client in the facility and submit the self-certification to LPA by POC due date.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by:Clients’ interviews and record review, C1 hit C2’s shoulder twice and with unknown reason which posed an potential risk for clients in care	8 9 10 11 12 13 14
	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.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC9099 (FAS) - (06/04)

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