197608297-3-28-2022-28-AS-MVAO-CDEUD6-20220412152901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608297
Report Date: 03/28/2022
Date Signed: 03/28/2022 03:09:45 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, 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
08/24/2020 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200824092728

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: 39	DATE:	03/28/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator / Ian Baker Staff / Gaye Lynn Mims		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident was hit by another resident breaking resident's eye glasses

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Resident was hit by another resident breaking resident's eye glasses". Upon arriving at the facility, LPA met with Administrator / Ian Baker who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 8/31/2020, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Administrator, Service Coordinator / Armine Toomanian from Frank D Lanterman’ s Regional Center (FDLRC) and Residents 1 and 3 (R1 and R3). LPA was unable to interview Resident 2 (R2) as R2 no longer resides at this facility and her whereabouts are unknown at this time. Also, copies of the following documents were obtained and reviewed in reference to R1 and R2;

• Functional Capability Assessment • Appraisal/Needs and Services Plan • Physician’s Reports

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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 28-AS-20200824092728

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: 03/28/2022

NARRATIVE

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The investigation revealed the following;
Allegation: Resident was hit by another resident breaking resident's eye glasses. The details of this allegation states that R2 hit R1 which led to R1's glasses to be broken.

According to the Unusual Incident/Injury Report submitted by the facility, on 1/28/2019, at approximately 9:45am, R2 went into R1's room and knocked the glasses off of R1's face. Based on record reviews and interviews conducted, there were no witnesses to the incident. R1 could not recall what caused R2 to go into her room and knock her glasses off of her face. This was an isolated incident and R1 did not sustain any injuries. R1's glasses were broken as a result of the incident but R1 received replacement glasses after seeing an Optometrist. After the incident, R2 was taken to Sherman Oaks Hospital for a psychiatric evaluation and did not return. R2's whereabouts are unknown at this time.
Per the Administrator, there have been no prior incidents involving R1 and R2 and both residents do not require one to one supervision. According to the Appraisal/Needs and Services Plan for R1, R1 has a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) and is fully independent. According to the Appraisal/Needs and Services Plan for R2, R2 is able to follow instructions and is described as outgoing and interacts well with others. Per the Administrator, FDLRC did not conduct an investigation regarding the incident involving R1 and R2. Although the incident happened involving R1 and R2, the facility staff could not have done anything different to prevent the incident from happening.

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.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC9099 (FAS) - (06/04)

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