LPA collected a copy of the on-the-job training logs, Identification and Emergency Information and conducted a short interview with the Administrator at 2:11pm. On 05/22/2025 starting at 10:02 a.m. LPA Mosley conducted the entrance interview and a brief physical plant tour to ensure there were no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 10:40 a.m. LPA conducted an in-person interview with two (2) staff, two (2) clients of which one (1) resided at the facility between 2015 - 2020, starting at 12:44 p.m., conducted telephonic interviews with North Los Angeles County Regional Center (NLACRC), Community Service Specialist (CSS) Gabriela Pinzon and Resident #1 (R1), inspected the kitchen/ food service area and supply closet, a record review and audit on client files, and obtained copies of pertinent documents relevant to the investigation.

On the allegation Staff made inappropriate comments towards residents it is the concern of the reporting party (RP) that between 2015 - 2020 facility staff told residents including R1 “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” and “It’s all in your head. Your mentally ill”. To investigate this complaint, LPA conducted in-person interviews with two (2) staff, two (2) clients of which one (1) resided at the facility between 2015 - 2020, telephonic interviews with NLACRC, CSS and R1 who no longer resides at the facility, conducted a record review and audit on client files including PNI funds. Interviews with staff revealed that they are unaware of any staff prior and now making inappropriate comments towards clients. Staff are unaware of any staff telling any of the clients including R1 “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” and “It’s all in your head. Your mentally ill”. Staff deny any knowledge or participation in making inappropriate comments towards clients. Interviews with clients who were at the facility between 2015 – 2020 state they are unaware of staff telling them “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” and “It’s all in your head. Your mentally ill” and staff did not say that to them. Furthermore, clients are unaware of any the staff saying, “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” and “It’s all in your head. Your mentally ill”. to any other client at the home.

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Clients had no issues or discrepancies with their PNI money. Interview with NLACRC CSS revealed that the same allegation was investigated with a determination of unsubstantiated as there was not enough evidence to support the allegation. Record review revealed that all PNI records for clients who were at the facility from 2015 -2020 was accounted for with signatures and receipts from the clients. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff made inappropriate comments towards residents is deemed unsubstantiated at this time.

On the allegation Staff threatened residents it is the concern of the reporting party (RP) that between 2015 - 2020 facility staff told residents including R1 “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” To investigate this complaint, LPA conducted in-person interviews with two (2) staff, two (2) clients of which one (1) resided at the facility between 2015 - 2020, telephonic interviews with NLACRC, CSS, and R1 who no longer resides at the facility, conducted a record review and audit on client files including PNI funds. Interviews with staff revealed that they are unaware of any staff prior and now threatening a client. Staff are unaware of any staff telling any of the clients including R1 “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” Staff deny any knowledge or participation in threatening a client. Interviews with clients who were at the facility between 2015 – 2020 state they are unaware of staff telling them “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” and staff did not say that to them. Furthermore, clients are unaware of any the staff saying, “Don’t tell the LPA’s anything, or we will deduct money from your PNI to pay for any deficiencies and it will be your fault.” to any other client. Clients had no issues or discrepancies with their PNI money. Interview with NLACRC CSS revealed that the same allegation was investigated with a determination of unsubstantiated as there was not enough evidence to support the allegation. Record review revealed that all PNI records for clients who were at the facility from 2015 -2020 was accounted for with signatures and receipts from the clients. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff threatened residents is deemed unsubstantiated at this time.

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On the allegation Staff falsified resident documents it is the concern of the reporting party (RP) that between 2015 - 2020 facility staff falsified resident documents including the Individual Program Plan (IPP) and Incident Reports for R1 stating they were violent and had inappropriate behaviors. To investigate this complaint, LPA conducted in-person interviews with two (2) staff, two (2) clients of which one (1) resided at the facility between 2015 - 2020, telephonic interviews with NLACRC, CSS, and R1 who no longer resides at the facility, conducted a record review and audit on client files. Interview with staff revealed that they have never falsified any documents including incident reports from 2015 – 2020. It was noted that the Administrator is the only one who submits documentation including incident reports on behalf of the facility. When incidents occur, the DSP will contact the Administrator and inform them of the incident. It was noted that the facility does not create the IPPs for the clients as it is a collaborative process with NLACRC, the client, and the home. Staff state they have never falsified client documents including the IPPs and Incident Reports for R1. Interview with clients revealed that they are unaware of the staff ever falsifying any of their documents. Clients are unaware of the staff ever falsifying any of the other clients’ documents. When asked about R1 clients responded that R1 had multiple outbursts and arguments with other clients, staff and had experienced it personally. Interview with NLACRC CSS revealed that the same allegation was investigated with a determination of unsubstantiated as there was not enough evidence to support the allegation. Record review revealed that two (2) incident reports were submitted in 2019 for R1 that reflect incidents described in interviews with clients who witnessed the behavior. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff falsified resident documents is deemed unsubstantiated at this time.

On the allegation Staff did not provide adequate food service to residents it is the concern of the reporting party (RP) that between 2015 – 2020 there were times when there was not enough food in the facility and the only time there was enough was when licensing would come for their annual visit and facility staff were making fast food runs for breakfast, lunch, and dinner. To investigate this complaint, LPA conducted in-person interviews with two (2) staff, two (2) clients of which one (1) resided at the facility between 2015 - 2020, telephonic interviews with NLACRC, CSS and R1 who no longer resides at the facility and inspected the kitchen/ food service area. Interviews with staff revealed that they have always provided adequate food service to their clients. Food is and has always been available to their clients. They always have more than enough food for their clients, if anything they provide more. The staff cook regularly and do not purchase fast food for breakfast, lunch, and dinner. Report continued on LIC 9099-C PAGE 5...

The staff provided adequate food service to residents between 2015 – 2020. The staff did not purchase fast food for breakfast, lunch, and dinner between 2015 – 2020. Interviews with clients revealed that food has always been available to them, and they have never had any issues with food quality at the facility. They had no issues between 2015 – 2020 with food at the facility. Between 2015 – 2020 they did not receive fast food for breakfast, lunch, and dinner. Interview with NLACRC CSS revealed that the same allegation was investigated with a determination of unsubstantiated as there was not enough evidence to support the allegation. Inspection of the kitchen and food service area on 05/22/2025 and 05/23/2025 revealed that the facility has a sufficient supply of two (2) day perishable and seven (7) day nonperishable food. LPA observed on 05/22/2025 and 05/23/2025 facility staff cooking meals for the current clients. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide adequate food service is deemed unsubstantiated at this time.

On the allegation Staff did not ensure residents had hygiene products it is the concern of the reporting party (RP) that in August of 2020 the facility did not have toilet paper. To investigate this complaint, LPA conducted in-person interviews with two (2) staff, two (2) clients of which one (1) resided at the facility between 2015 - 2020, telephonic interviews with NLACRC, CSS, and R1 who no longer resides at the facility and inspected the supply closet. Interviews with staff revealed that they have always had a sufficient supply of hygiene products for their clients including toilet paper. They have always made hygiene products available to their clients including in August of 2020. They have consistently provided hygiene products, including toilet paper, to their clients without any denial or shortage. Interviews with clients revealed that they have always had toilet paper available to them. They have never had any issues with not having hygiene products available to them including toilet paper. In August of 2020 they had toilet paper available to them. They always had products to clean themselves. Inspection of the supply closet revealed that the facility has a sufficient supply of hygiene products including toilet paper available for client use. Interview with NLACRC CSS revealed that the same allegation was investigated with a determination of unsubstantiated as there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not ensure residents had hygiene products is deemed unsubstantiated at this time.

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On the allegation Staff did not treat residents equally it is the concern of the reporting party (RP) that between 2015 – 2020 clients who were sick were treated differently. To investigate this complaint, LPA conducted in-person interviews with two (2) staff, two (2) clients of which one (1) resided at the facility between 2015 - 2020, and a telephonic interview with NLACRC, CSS, and R1 who no longer resides at the facility. Interview with staff revealed that they treat all their clients equally with dignity and respect. The staff does not treat the clients differently if they are sick. The staff will attend to the clients needs to ensure they are healthy and safe. The staff are unaware of any staff member treating the clients differently because they are sick. Furthermore, staff deny that between 2015 – 2020 clients who were sick were treated differently. Interview with clients revealed that they are unaware of staff not treating all the clients equally. They have never experienced the staff not treating them equally. From 2015 – 2020 they did not experience the staff treating them differently if they were sick. They did not witness the staff treat clients who were sick differently in 2015 – 2020. Interview with NLACRC CSS revealed that the same allegation was investigated with a determination of unsubstantiated as there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not treat residents equally is deemed unsubstantiated at this time.

No deficiencies were observed or cited during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.