197608297-9-10-2021-28-AS-WSHO-C6UPR3-20210914113203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608297
Report Date: 09/10/2021
Date Signed: 09/10/2021 09:35:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210819104644

FACILITY NAME:	BELLA VISTA		FACILITY NUMBER:	197608297
ADMINISTRATOR:	BAKER, IAN		FACILITY TYPE:	740
ADDRESS:	1760 N FAIR OAKS AVE		TELEPHONE:	(626) 794-4103
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	72	CENSUS: 38	DATE:	09/10/2021
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Administrator, Ian Baker		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff did not prevent an inappropriate interaction between clients while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst's (LPA's) Vasallo and Mora conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with administrator, Ian Baker and explained the reason for the visit. The initial complaint visit was conducted on 8/25/21.

The investigation consisted of the following: Interviews were conducted with 6 staff and 4 residents. LPA reviewed Resident #1’s (R1) records and obtained a resident and staff roster. Camera footage was reviewed for the night of 8/18/21 when the incident allegedly occurred. Staff from R1’s previous facility were also interviewed.

The investigation revealed the following: It’s alleged R1 was inappropriately touched by Resident #2 (R2) at the facility. Allegedly R2 touched R1’s breasts. Allegedly the incident occurred on 8/18/21. LPA reviewed camera footage from the cameras located in the hallway. R1 and R2 had rooms next to each other.
Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

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 28-AS-20210819104644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELLA VISTA	FACILITY NUMBER: 197608297
	VISIT DATE: 09/10/2021

NARRATIVE

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At 12:02 am R2 is seen in the hallway and then enters R1's room. R2 was in the room approximately 5 seconds and walks back to his/her room. A few seconds pass and R2 is seen exiting his/her room again and entering R1's room again. R2 is there again another 5 seconds and walks out and back to his/her room. R1 is then seen entering R2’s room at 12:03 am. R1 is seen leaving R2’s room at 12:05 am and back to his/her room. No other movement was seen that night.

Residents interviewed deny ever witnessing R2 harass R1 or anyone else in the facility. R1 indicated the incident did occur but reported there were no other witnesses. R2 denied the allegation and indicated that R2 and R1 were friends. Staff interviewed indicated they never witnessed the incident and reported that R2 does not have a history of such behavior.

Administrator from R1’s previous facility was interviewed. That administrator reported that R1 had a history of fabricating stories of sexual encounters with strangers. Allegedly R1 made those allegations on a regular basis and would often call police. Police responded to the facility after this allegation was made. Police interviewed both R1 and R2 and there were no arrests made. Police provided the facility with report numbers from previous times R1 made allegations at the previous facility.

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, therefore the allegation is unsubstantiated.

Exit interview held. A copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC9099 (FAS) - (06/04)

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