191592625-9-1-2022-28-AS-RORN-CJ9U6C-20220914151808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592625
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:05:43 PM

Unsubstantiated

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
08/26/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220826110440

FACILITY NAME:	DELHAVEN SOUTH ACTIVITY CENTER		FACILITY NUMBER:	191592625
ADMINISTRATOR:	SEAL, BARBARA		FACILITY TYPE:	775
ADDRESS:	15135 FAIRGROVE AVE.		TELEPHONE:	(626) 917-9789
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY:	50	CENSUS: 22	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Eric Benavidez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Client sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Program Director Eric Benavidez and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Program Director Eric Benavidez, Staff 1-3 (S1-3) and attempted to interview Clients 2-4 (C2-4). LPA additionally conducted telephone interviews with facility administrator of Kendall Guest Home 1 Ana Gallegos, San Gabriel/ Pomona Regional Center (SGPRC)Service Coordinator Alma Hernandez and Quality Assurance Specialist Michelle Daniels. LPA obtained copies of Staff and Client Rosters. LPA reviewed C1's file and collected copies of Physical Exam, Observation note dated 8/25/22 and SGPRC Individual Program Plan (IPP). LPA conducted a tour of facility which included observations of client activity area and outside patio area.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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-20220826110440

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: DELHAVEN SOUTH ACTIVITY CENTER	FACILITY NUMBER: 191592625
	VISIT DATE: 09/01/2022

NARRATIVE

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Investigation revealed the following: Regarding allegation, Client sustained injuries while in care, it is alleged that C1 returned to their home with unusual bruising on 08/24/22 and 08/25/22. The bruising was observed on C1's right arm and C1 stated in non-verbal gestures that the bruising occurred at their day program. Interviews conducted with Program Director and S1-3 revealed that nothing unusual occurred with C1 on 8/24/22 or 8/25/22 that might have caused C1 to sustain bruising on their right arm. S3 stated that on 08/25/22 as C1 arrived at the program, at approximately 9am, C1 pointed to their right arm. S3 stated that C1 was wearing a shirt with a sleeve and when S3 moved C1's sleeve up, the bruise was noticed in the upper bicep area. S3 reported their observations to S1-2 and the observations were noted down. Interview with S2 revealed that all clients are visually checked upon arrival but removal of clothing items is not performed. S2 stated that staff only learned of C1's bruise until C1 pointed it out to S3 and then also when S2 called C1's home to inform them of another unrelated incident involving C1 at which time the home administrator, Ana Gallegos, reported that she had observed a bruise on C1 on 08/24/22. S1-3 all stated that bruising was not observed on C1 on 8/24/22 and C1 did not point to their right arm. Interviews conducted with SGPRC staff revealed that their investigation did not reveal anything of concern and stated that C1's has behaviors such as running with their eyes closed which lead to C1 bumping into things. Interview with Kendall Guest Home 1 Administrator Ana Gallegos also revealed that C1 runs with their eyes closed and does bump into things when they exhibit such behavior. LPA's review of C1's IPP corroborated the information provided by both SGPRC staff and Kendall Guest Home 1 Administrator regarding C1 running with their eyes closed and running into people and or things. LPA attempted to interview C2-4 but was not able to properly interview them as they are non-verbal clients.

During facility tour, LPA observed clients participating in activities and did not observe anything of concern. LPA observed the facility to be clean during the time of the visit and did not observe any items obstructing any doors or passageways. Based on statements gathered from interviews conducted with staff, SGPRC staff, Kendall Guest Home 1 Administrator and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Program Director Eric Benavidez.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC9099 (FAS) - (06/04)

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