197607735-7-14-2022-11-AS-UCOL-CHF24K-20220818170403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607735
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:46:06 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
07/12/2022 and conducted by Evaluator Jey Cardenas

COMPLAINT CONTROL NUMBER: 11-AS-20220712154336

FACILITY NAME:	4219 W. 162ND STREET HOME		FACILITY NUMBER:	197607735
ADMINISTRATOR:	CHARMILEY VENTURA		FACILITY TYPE:	740
ADDRESS:	4219 W. 162ND STREET		TELEPHONE:	(424) 247-8936
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY:	3	CENSUS: 3	DATE:	07/14/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lead staff Kacey Princess Uci		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff inappropriately handle residents in a rough manner
Staff yells to residents 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 allegations listed above. Upon arrival at the facility LPA meet with Lead caregiver, Usi. LPA explained the reason for today’s visit and conducted a Covid-19 risk assessment, based on the assessment facility is clear of covid-19 infection.

The investigation consisted of following: During today’s visit on 7/14/22 LPA Cardenas toured plant, requested/ resident roaster, reviewed three (3) resident files and Staff#3 (S3) file. Interviewed Administrator, Melanie Estapa and S3 via telephone, Staff#1-Staff#2 (S1-S2) were interviewed in person, attempted to interview Residente#1 – Resident#3 (R1-R3), attempted to interview S5-S8 via telephone, but were unavailable. Attempted to interview Regional Center Service Coordinator (SC).

Complaint received alleging that since April2022 S3 has been observed yelling at and handling residents in a rough manner. Allegedly there has been multiple incidents that have happened since then,

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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 11-AS-20220712154336

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: 4219 W. 162ND STREET HOME	FACILITY NUMBER: 197607735
	VISIT DATE: 07/14/2022

NARRATIVE

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(continued pg2)

however allegations were recently reported near the end of June2022. Specific dates of incidents were not provided.
Per record review: Unusual Incident Report (UIR); on 6/29/22 Licensee Greg Andres received a call from staff reporting grievance, alleging that S3 yells at and handles residents in a rough manner. It is also noted that S3 used personal phone during shift to take a picture of S4 sleeping on the job. Per training records S3 received zero tolerance/ Abuse/ SIR Reporting training on a yearly basis from 2019-2022. Per facility internal notes reviewed; LPA didn’t find documentation with indication of staff handling residents in a rough manner, nor yelling.

Regarding allegation- Staff inappropriately handle residents in a rough manner. On 7/14/22 LPA interviewed administrator Melanie Estapa who indicates that on 6/29/2022 S4 reported S3 for handling residents in a rough manner and yelling. These allegations were investigated by facility; all staff were interviewed and none of staff reported witnessing S3 or any other staff handling residents in a rough manner nor yelling at residents. Melanie has observed S3’s interactions with residents and staff handles residents well. These allegations are an isolated incident and have never been reported in the past. Residents families have not reported any concerns regarding staff care. All staff receive yearly zero tolerance/ abuse/ reporting in-service training. In addition, during the monthly staff meetings these items are also reviewed. On 7/14/22 LPA interviewed S1-S3 who denied yelling and handling residents roughly. All three staff indicate that they have not witnessed other staff handle residents in a rough manner. All three (3) resident families are involved and none of the families have complained nor have concerns regarding residents being mishandled, staff treat residents with respect and dignity. On 7/14/22 LPA Cardenas attempted to interview there (3) out of there (3) residents; however due to cognitive impairment a statement couldn’t be obtained. On 7/14/22 LPA Cardenas contacted three (3) out of three (3) witnesses; however, was only able to speak with one (1) witness (W1). W1 indicates staying in touch with resident via phone. About two years ago W1 visited the facility in person and observed staff interaction with residents; residents are handled well. W1 has no concerns about the facility staff care, “care is great.” Staff working there are dedicated.

Regarding allegation- Staff yells at residents in care. During interview with administrator Melanie Estapa, she indicated never witnessing staff yell at residents, not obtaining a report about staff yelling at residents. S3 has a loud voice and that may have been factor for the allegation regarding yelling. None of the staff have

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220712154336

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: 4219 W. 162ND STREET HOME	FACILITY NUMBER: 197607735
	VISIT DATE: 07/14/2022

NARRATIVE

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(continued pg3)

reported staff yelling at residents. During interview with S1-S3 they denied yelling at residents. They indicated that they have not witnessed staff yelling at residents. None of their coworkers have reported witnessing another staff yelling at residents. During attempted interview with R1-R3, LPA was unable to obtain statement. During interview with W1, witnessed reported having no concerns.

Per observations made- LPA observed residents were well groomed, cleaned and there were no marking's on body that would indicate residents are being handled roughly.

Based on LPA’s interviews, record reviews and observation LPA did not find sufficient evidence to support the allegations, 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: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

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