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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800850
Report Date: 11/22/2021
Date Signed: 11/22/2021 06:01:44 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
10/25/2021 and conducted by Evaluator LaJean Nicole Spencer
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211025093525
FACILITY NAME:PAYNE CARE CENTERFACILITY NUMBER:
197800850
ADMINISTRATOR:WILLIAMS, LAVONIA PAYNEFACILITY TYPE:
735
ADDRESS:181 E. ARROW HIGHWAYTELEPHONE:
(909) 282-2964
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:4CENSUS: 4DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darlene Carcoba, house managerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not allow resident to visit at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Spencer met with house manager Darlene Carcoba and discussed the purpose of today's visit.

The investigation consisted of the following: During the initial visit on 11/2/21, LPA Spencer took a tour of the physical plant and interviewed the administrator, staff #1-2 (S1-S2) and clients #1-2 (C1-C2). C2 was non-verbal so interview was discontinued. During the course of the investigation, LPA interviewed clients #3-4 (C3-C4), staff #3 (S3), staff at C3's placement agency (P1), responsible party of C3 (RP1) and friends of C3 (F1-F2). LPA requested a copy of the staff roster, client roster, and admissions agreement.

***See LIC9099C for continuation of the narrative***
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: LaJean Nicole Spencer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 4
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
10/25/2021 and conducted by Evaluator LaJean Nicole Spencer
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211025093525

FACILITY NAME:PAYNE CARE CENTERFACILITY NUMBER:
197800850
ADMINISTRATOR:WILLIAMS, LAVONIA PAYNEFACILITY TYPE:
735
ADDRESS:181 E. ARROW HIGHWAYTELEPHONE:
(909) 282-2964
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:4CENSUS: 4DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darlene Carcoba, house managerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not allow resident to have a phone at facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Spencer met with house manager Darlene Carcoba and discussed the purpose of today's visit.
The investigation revealed the following: All staff stated that clients are allowed to have personal cell phones at the facility if provided by their responsible party. C1, C3, and C4 stated clients are allowed to have cell phones. C2 was non-verbal so interviews were discontinued. C1 stated that C1 has a cell phone and C3 stated that C3 used to have a cell phone but lost the phone and has not had it replaced yet. RP1 pays for C3's cell phone and stated that has not replaced it but that the facility allows clients to have cell phones. P1 also stated that clients are allowed to have phones but that C3 lost the phone.
Based upon interviews conducted, the findings indicate that although 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 found to be UNSUBSTANTIATED. An exit interview conducted with the house manager and a copy of this report and appeal rights provided.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: LaJean Nicole Spencer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20211025093525
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: PAYNE CARE CENTER
FACILITY NUMBER: 197800850
VISIT DATE: 11/22/2021
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
Staff does not allow resident to visit at the facility

It was alleged that staff refused to allow a client to have visitors at the facility. In interviews, the administrator and staff 1-3 (S1-S3) admitted that they did not allow C3 to have a visitor (F1) at the facility because the visitor refused to show the vaccination card and began yelling and using profanity when asked to show the vaccination card. Staff stated that F1 eventually showed his vaccination card but was later asked not to return to the facility due to the incident. F1 stated that on 9/11/21, F1-F2 came to visit C3 at the facility and had called ahead of time to arrange an outing with C3. F1 stated that S3 asked to see their vaccination cards and F1 declined to show the card because F1 was told that vaccination cards are not required if a client was going on an outing with a visitor. F2 also stated that they had come to the facility to take C3 on an outing and that S3 asked to see their vaccination cards. F1-F2 stated that after the visit, C3 informed them that clients were not supposed to go out on outings with visitors and that they were not allowed to visit at the facility anymore due to the incident that occurred. F1 stated that F1 attempted to visit on another occasion on 11/5/21 and was denied being able to visit or see C3 outside of the facility. C1-C2 stated that they are allowed to have visitors at the facility, while C3 stated that F1-F2 are not allowed to visit the facility because they are causing problems. RP1 stated that the visitor was not allowed to visit at the facility because they were disrespectful to staff and refused to show the vaccination card. P1, staff member at the placement agency, was made aware of the situation and stated that staff refused visitation due to the visitor using profanity and not following the rules to show the vaccination card. S2, assistant administrator, stated that the visitor is allowed to visit C3 at an outside location but will not be allowed on the property. The admissions agreement provided did not mention the facility's visitation policy.

Based on LPA’s interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6, is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the house manager along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: LaJean Nicole Spencer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20211025093525
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: PAYNE CARE CENTER
FACILITY NUMBER: 197800850
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
85072(b)(4)
1
2
3
4
5
6
7
85072(b)(4) Personal Rights: To have visitors, including advocacy representatives, visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients. This requirement was not met as evidenced by...
1
2
3
4
5
6
7
The house manager stated that the facility will train all staff on PIN 21-40-ASC regarding visitation and vaccination requirements and will send a copy of training logs to CCL by POC due date.
8
9
10
11
12
13
14
Based upon interviews, the licensee did not ensure that clients were permitted to have visitors at the facility and that staff were provided with the proper COVID-19 protocol for visitors. This poses a potential personal rights risk to persons in care.
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.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: LaJean Nicole Spencer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4