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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607404
Report Date: 04/21/2022
Date Signed: 04/21/2022 12:33:51 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2021 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20210908095313
FACILITY NAME:CREATIVE MINDS ADP, INC.FACILITY NUMBER:
197607404
ADMINISTRATOR:JOSE CHAVEZFACILITY TYPE:
775
ADDRESS:6045 WOODMAN STREETTELEPHONE:
(818) 780-1641
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:105CENSUS: 0DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Jose Chavez, Program Director TIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff not reporting incidents to client's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit to deliver findings for the above allegation. At 10:07 a.m., LPA met with the Program Director, Jose Chavez and explained the reason for the visit. The day program currently does not have clients inside the facility but are operating through community outings and alternative services.

During the initial visit on 09/14/2021, between 1:05 p.m. and 2:20 p.m., LPA Emily Peraldi interviewed the Program Director and three (3) staff. Additionally, on 09/14/2021 at 10:22 a.m., LPA Peraldi reviewed client records and obtained copies of pertinent documents. Between 09/14/2021 and 10/21/2021, LPA Peraldi interviewed six (6) client’s parents/care providers.

Continued on LIC 809-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
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 29-AS-20210908095313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CREATIVE MINDS ADP, INC.
FACILITY NUMBER: 197607404
VISIT DATE: 04/21/2022
NARRATIVE
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Regarding the allegation: Staff not reporting incidents to client's authorized representative.

On 09/08/2021, it was alleged that the day program staffs did not report to Client#1’s (C1’s) authorized representative/ conservator regarding an incident that occurred during the day program on 09/03/2021. On 09/03/2021, C1 was attending a community outing and did not feel well and appeared to be pale. The day program staff called emergency services for C1. The day program alerted C1’s group home administrator in which C1’s group home administrator arrived shortly. The Program Director arrived after being notified of the incident. C1 was transported to the hospital after the arrival of both the Program Director and C1’s group home administrator. Based on record review and interviews, it was revealed that C1’s group home administrator contacted C1’s conservator directly while the Program Director handled the incident and the other clients that were present. The Program Director explained that the day program will start calling both parties from now on.

Based on the information obtained, there is sufficient evidence to support the claim that the day program did not report to Client#1’s (C1’s) authorized representative regarding an incident. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and report reviewed with Program Director. A copy of reports and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210908095313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CREATIVE MINDS ADP, INC.
FACILITY NUMBER: 197607404
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
82061(e)
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82061(e) Reporting Requirements
(e) The items specified in Sections 82061(b)(1)(A) through (I) also shall be reported to the client’s authorized representative, if any.
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
- report all incidents to both parties moving forward, especially C1’s conservator.
- In service training and discussion in regard to the attached regulation.
Program Director will send LPA Peraldi proof by POC due date.
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Based on record review and interviews, the licensee did not comply with the section cited above, as the facility failed to directly report to Consumer#1’s (C1’s) authorized representative/ conservator regarding an incident, which poses a potential health and safety risk to residents in care.
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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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
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