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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800850
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:29:07 AM

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
05/27/2022 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220527151026
FACILITY NAME:PAYNE CARE CENTERFACILITY NUMBER:
197800850
ADMINISTRATOR:WILLIAMS, LAVONIA PAYNEFACILITY TYPE:
735
ADDRESS:181 E. ARROW HIGHWAYTELEPHONE:
(909) 506-4428
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:4CENSUS: 4DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator, Lavonia WilliamsTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff are not providing appropriate care and supervision to a client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with staff member, Romelia Becerra. A short time later, Administrator Lavonia Williams arrived and assisted with the visit.

The investigation consisted of the following: Interviews were conducted with 2 staff and 3 clients. Client #1's (C1) file was reviewed which included Individual Program Plan (IPP), recent lab work, and medication records.

The investigation revealed the following: It's alleged C1 is not taking his/her proper medication and not seeking medical care. C1 was interviewed and indicated he/she takes medication on a daily basis. C1 reported a recent diagnosis which would mean a change of diet and new medications. C1 reported that staff assist with meeting his/her needs. C1's medications were reviewed. The medications are documented properly and appears C1 is taking the medications daily.
Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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 2
Control Number 28-AS-20220527151026
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: 06/02/2022
NARRATIVE
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Staff interviewed reported the new diagnosis and indicated C1 has to change his/her diet and reported a change of medications. The new diagnosis was discovered after C1 had routine labs performed. C1 has not had any recent hospitalization's. There is insufficient evidence to prove the facility has not provide appropriate care to C1.

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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2