191601613-8-5-2022-11-AS-UCOL-CJMSS9-20220926140733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601613
Report Date: 08/05/2022
Date Signed: 08/05/2022 03:38:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2022 and conducted by Evaluator Jey Cardenas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220727130322

FACILITY NAME:	WILMINGTON GARDENS		FACILITY NUMBER:	191601613
ADMINISTRATOR:	FLORES,V.ANDT.		FACILITY TYPE:	735
ADDRESS:	1311 WEST ANAHEIM STREET		TELEPHONE:	(310) 835-6366
CITY:	WILMINGTON	STATE: CA	ZIP CODE:	90744
CAPACITY:	48	CENSUS: 47	DATE:	08/05/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Fey Pacific Ador		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident caused injury to another resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jey Cardenas conducted an initial 10- day complaint visit to the above facility to investigate allegation listed above. Upon arrival at the facility LPA meet with caregiver C.S LPA explained the reason for today’s visit and conducted a Covid-19 risk assessment, based on the assessment facility has covid-19 positive cases.

The investigation consisted of following: During today’s visit on 08/05/22 LPA Cardenas toured plant, requested staff and resident roaster, reviewed three (3) client files and requested records pertinent to the investigation. Interviewed Administrator, Flores, Victorio via telephone and Staff#1-Staff#3 (S1-S3), Client#1 – Client#5 (C1-C5).

It is being alleged that a C1 was hit by another client in care, consequently C1 is complaining of left shoulder, neck, and upper back pain; no bruising was reported.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

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 11-AS-20220727130322

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
	VISIT DATE: 08/05/2022

NARRATIVE

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(continued pg2)

Regarding allegation client caused injury to another client in care. Per client interviews; On 8/5/22 LPA Cardenas interviewed C1 who stated that client has not witnessed any client on client physical altercations. However, about 3 to 4 weeks client was slapped by another client (name provided to LPA). The Slap lead to shoulder, neck and back pain. C1 doesn’t know why they were slapped. C1 states S1 witnessed the physical altercation incident. During interviews with C2-C5 all four clients reported that they have not witnessed client on client physical altercations. One out of four clients reported being scratched by another client in care at the facility.

Per staff interviews; On 8/5/22 LPA interviewed administrator, Flores who indicates that he is not aware of any recent client on client physical altercations, no incidents have been reported. Flores is also not aware of any recent hospitalization's due to physical altercations. Per interview with S1 staff states that two weeks ago C1 was heard screaming in the lobby. S1 went to check in on client and was told by the client that an individual slapped them. C1 was unable to provide with individuals name nor, where the slapping occurred. S1 hasn’t witnessed any physical altercations involving C1 nor other clients. Paramedics were called to transport to hospital due to C1 complained of pains. S1 was the only staff on shift during the incident. Per interview with S2 staff the incident involving C1 was reported by staff, however C1 was transported to the emergency room and has not returned to facility due to client tested positive for covid-19. Staff has not witnessed any client on client physical altercations. S3 is unaware of physical altercation involving C1. Staff interviewed were unaware of any individual with the name that C1 provided to LPA.

Per witness interview, LPA confirmed that the individual's name C1 provided is not of a facility client, nor anyone associated to the facility.

Per facility internal notes reviewed; LPA didn’t find documentation with indication of client on client physical altercations.

Based on LPA’s interviews LPA did not find sufficient evidence to support the allegation, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report to be provided to facility representative.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC9099 (FAS) - (06/04)

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