197608297-6-1-2023-28-AS-RORN-CV6U63-20230829151741

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608297
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:28:54 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, 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
05/24/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230524172942

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: 34	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator- Ian Baker		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff interacted with a resident in an inappropriate manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon made an unannounced complaint visit regarding the allegation above and met with Administrator Ian Baker. The purpose of the visit was discussed.

On todays visit, LPA interviewed Administrator, Staff #3 and Staff #4 (S3, and S4). Telephonically interviewed Staff #1 (S1) and attempt to interview Staff #2 (S2). LPA interviewed Residents #1-#4 (R1,R2,R3 and R4). LPA interviewed Lantherman Regional Center Service Coordinator via telephonically. Regional Center will provide a Corrective Action Plan to LPA Calderon via email when report is readily available. LPA Calderon collected R1's Physician Report, Individual Program Plan, Pre-Placement Appraisal and Appraisal Needs and Service Plan. LPA from R1 collected letter regarding above incident. Ian on 5/26/23 submitted to Licensing a Unusual Incident Report (UIR) -LIC 624. LPA collected Personal Right training's from S1, and S2.

see 9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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-20230524172942

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: 06/01/2023

NARRATIVE

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Regarding allegation: Staff interacted with a resident in an inappropriate manner. Based on interviews conducted by LPA Calderon with Administrator Ian Baker stated S1 did admit to doing inappropriate hand gestures towards R1 but was not intentional. Ian stated gesture was inappropriate and staff training will occur. Interview with S1 admitted doing the hand gesture towards R1 and at the time did not preserve R1 would take it offensively. Interview with S3 stated staff have treated residents inappropriately commenting things towards residents that are lack of respect and not professional. LPA interviews with Residents, R1 reported the hand gesture that was done by S1 was inappropriate/ wrong and made R1 feel uncomfortable. Interview with R3 stated staff have interacting inappropriately asking personal questions. UIR sent to Licensing reported by Ian Baker, reporting incident occurring on 5/20/23. Interviews with staff and resident and record review collaborate with this allegation.

Deficiencies were cited per Title 22 Division 6 Chapter 8 see 9099-D. Appeal rights and copy of this report was provided to Ann Hamilton. An exit interview conducted.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230524172942

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2023 Section Cited CCR 87468.1	1 2 3 4 5 6 7	Personal Rights of Resident in all Facilities. Each resident shall be accorded dignity in his/her personal relationships with staff, residents and other persons. On 6/1/23 LPA Calderon interviewed staff(s) and resident(s).	1 2 3 4 5 6 7	Per Administartor reported that S1 was out on a leave, and training in sexual harrasment training will occur. Licensee/ Administrator will go over Personal Right Regulations 87468.1 and sexual harrasment training will provide proof to LPA Calderon by 6/30/23.
	8 9 10 11 12 13 14	S1 admitted hand gestures and that at the time did not think R1 would take offensively. R1 stated gesture and how matter was approached was inappropriate felt that S1 made her feel uncomfortable.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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