191600215-9-18-2025-11-AS-SCIS-DM4W25-20251003165346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600215
Report Date: 09/18/2025
Date Signed: 09/18/2025 03:55:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2025 and conducted by Evaluator Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250819114926

FACILITY NAME:	WITHERS ADULT RESIDENTIAL FACILITY #3		FACILITY NUMBER:	191600215
ADMINISTRATOR:	PEGGIE M. WITHERS		FACILITY TYPE:	735
ADDRESS:	1306 E. PECK ST APT. D		TELEPHONE:	(310) 604-0069
CITY:	COMPTON	STATE: CA	ZIP CODE:	90221
CAPACITY:	7	CENSUS: 6	DATE:	09/18/2025
		UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Lynda McCullough		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff physically abused resident.
Staff did not provide adequate supervision resulting in resident wandering away from facility.

INVESTIGATION FINDINGS:

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On 09/18/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to further investigate the allegations listed above and deliver findings. LPA met with Direct Support Personnel, Lynda McCullough and Margaret Pippen, and explained the purpose of the visit. LPA was granted access to the facility.

The investigation consisted of the following: On 08/28/25, LPA Gonzalez conducted interviews with staff #1-#3 (S1-S3) and clients #1-#2 (C1-C2). LPA requested and reviewed the following documents: staff roster, resident roster, Physician’s report, Personal Rights, South Central Los Angeles Regional Center Individual Program Plan (IPP), and Special Incident Report (dated: 08/15/25). Additionally, LPA and Lynda McCullough toured the facility. On 08/29/25, LPA Gonzalez conducted an interview with witness #1 (W1). On 09/18/25, LPA Gonzalez conducted an interview with clients #3-#5 (C3-C5) and attempted to interview client #6 (C6).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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 3

Control Number 11-AS-20250819114926

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WITHERS ADULT RESIDENTIAL FACILITY #3	FACILITY NUMBER: 191600215
	VISIT DATE: 09/18/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff physically abused a resident. It is being alleged that staff at the facility hit a resident in the back of the head and on their chest. On 08/22/25, between 01:00 PM and 02:00 PM, LPA Gonzalez conducted interviews with S1-S3. Of those interviewed, 3 out of 3 staff denied the allegation. 3 out of 3 staff said they treat all residents at the facility with dignity and respect.

On 08/28/25, between 11:35 AM and 12:00 PM, LPA Gonzalez interviewed C1-C2, and on 09/18/25, between 02:45 PM and 03:30 PM, LPA Gonzalez interviewed C3-C5 and attempted to interview C6 but was unable to as the client is non-verbal. Of those interviewed, 4 out of 5 clients could not corroborate with the allegation. 5 out of 5 clients said that staff treat them with dignity and respect. 5 out of 5 clients said staff provide a safe and healthy environment within the facility and that they feel safe in the home.

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, as a result, the allegation is Unsubstantiated.

Allegation: Staff did not provide adequate supervision resulting in a resident wandering away from the facility. On 08/22/25, between 01:00 PM and 02:10 PM, LPA Gonzalez conducted interviews with S1-S3. Of those interviewed, 3 out of 3 staff denied the allegation. 3 out of 3 staff said they supervise all their clients. S1 stated that if a client is able to leave the facility unassisted, staff cannot keep them from going out into the community. S1 said it’s the clients right, and that staff just has the clients sign in and out and provide supervision. S1 said that there are two clients who have transportation cards, and they can go wherever they want. S1 that if a client leaves and doesn’t come back within 4-5 hours, then they will start looking for them and will call law enforcement to report them missing.

On 08/28/25, between 11:35 AM and 12:00 PM, LPA Gonzalez interviewed C1-C2, and on 09/18/25, between 02:45 PM and 03:30 PM, LPA Gonzalez interviewed C3-C5 and attempted to interview C6 but was unable to as the client is non-verbal. Of those interviewed, 4 out of 5 clients could not corroborate with the allegation. 5 out of 5 clients said that staff provide the necessary supervision. 5 out of 5 clients said they are satisfied with the services provided to them at the facility.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250819114926

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WITHERS ADULT RESIDENTIAL FACILITY #3	FACILITY NUMBER: 191600215
	VISIT DATE: 09/18/2025

NARRATIVE

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LPA Gonzalez conducted a review of records, and it revealed the following. A Special Incident Report (dated: 08/15/25) noted that on 08/14/25, C1 arrived at the facility from their day program. As C1 was getting off the bus, they started walking away from the facility. The bus driver asked C1 where they were going, and C1 said they needed to clear their head, and said they would be back. On 08/15/25, at approximately 06:40 AM, facility staff called 911 and filed a missing person report. South Central Los Angeles Regional Center Individual Program Plan (dated: 03/28/24) page 7 of 17 noted that C1 does not require supervision to prevent injury/harm. Page 11 of 17 noted that C1 independently goes out into the community for walks or shopping. Physician’s Report (dated: 07/18/24) notes that C1 is ambulatory, and able to ambulate without assistance. It also notes that C1 is able to leave the facility unassisted.

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, as a result, the allegation is Unsubstantiated.

No deficiency were cited during this investigation.

An exit interview was conducted, and a copy of this report was provided to Lynda McCullough.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

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