<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608215
Report Date: 12/20/2021
Date Signed: 12/20/2021 12:24:09 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2019 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20190830150327
FACILITY NAME:PACOIMA ADCFACILITY NUMBER:
197608215
ADMINISTRATOR:VERJINE EGIANFACILITY TYPE:
775
ADDRESS:13117 VAN NUYS BLVDTELEPHONE:
(818) 434-0004
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY:90CENSUS: 0DATE:
12/20/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Verjine Egian/ AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to notify responsible party of client's change of condition in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegation. LPA was greeted by the facility administrator and all COVID-19 protocols were preformed before allowing the LPA entry into the facility. There are currently no clients receiving services at this location however three staff members were present.

Allegation 1. Facility staff failed to notify responsible party of client's change of condition in a timely manner.
LPA was able to gather documentation, conduct interviews with staff and view video from the day of the alleged incident in order to come to a finding for this allegation. Interviews indicated that the client in question (C1) was assisted to the restroom by C1's 1 on1. C1's 1 on 1 is not an employee of the facility and assisted C1 through a company called, Right Choice. After using the restroom, C1 did not move closer to C1's wheel chair and the 1 on 1 lowered C1 to the floor. The 1 on 1 then came out of the bathroom and asked for assistance from a facility staff member.
Continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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 2
Control Number 31-AS-20190830150327
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACOIMA ADC
FACILITY NUMBER: 197608215
VISIT DATE: 12/20/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In an interview conducted with the facility staff member who assisted C1 up, staff indicated that the 1 on1 stated that C1 was lowered and placed to the ground. Staff indicated that C1 did demonstrate any pain either verbally or through facial expressions. Staff stated that C1 was inspected for any bumps or bruising and none were observed. C1 then was able to grab the grab bar in the bathroom while the 1 on1 and the facility staff helped C1 back to C1's wheel chair. Staff stated that C1 did not show any signs of pain and asked for a snack.
The facility administrator and the administrator assistant were also present the day of the incident and were also interviewed. Both the administrator and the administrator assistant recalled the incident taking place and stated that C1 never showed any sign of discomfort or pain. Both stated that C1 had an eventful day at the facility and engaged in activities and lunch and never displayed feelings of discomfort.
Video of the day in question was shown to the LPA during todays visit. The video does not show the incident occurring since there are no cameras in the bathroom, however the video does show that the 1 on 1 staff brings C1 to the restroom at about 10:10 AM. At about 10:18 AM, the 1 on 1 is seen asking for help and the facility staff goes into the bathroom to assist. At 10:25 AM, C1 is seen coming out of the bathroom and going to the dining area to have a snack. At about 1:55 PM C1 is observed going outside with C1's 1 on 1. At 2:30 PM C1 is brought back into the facility where C1 is observed watching TV and then at 3:00 PM, C1 is seen leaving for the day and transported by Keolis Transportation.
An Incident Report was submitted to Licensing and to Regional Center regarding this incident, by Right Choice. Staff interviews indicated that after C1 was assisted up, there was no signs of injury and there was no change in the condition of C1.

Based on interviews conducted, video observed and a review of documentation gathered, this allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted and report issued. `
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2