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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800850
Report Date: 02/23/2023
Date Signed: 02/23/2023 05:17:48 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
02/17/2023 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20230217101418
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:
02/23/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Darlene Carcoba- House ManagerTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Facility retaliating against resident.
Resident does not have access to a phone.
Facility disposed of resident's mail.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an initial unannounced visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Direct Support Professional (DSP) Larry Walker and explained the purpose for the visit. House Manager Darlene Carcoba arrived shortly after and assisted with the visit.

During today's visit, LPA Maldonado obtained a copy of the client and staff roster and the following documents for Client#1 (C1): Facesheet, Physician's Report, Individual Program Plan (IPP), copy of police reports regarding C1 (if any), and copy of restraining order regarding C1 (if any). LPA also conducted interviews with C1 and Staff# 1-3 (S1-S4).

The investigation revealed the following:

(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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-20230217101418
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: 02/23/2023
NARRATIVE
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Regarding allegation: Facility retaliating against resident.
It is alleged that due to previous complaints filed regarding C1, facility staff is retaliating against C1 by not allowing C1 to see/speak to friends. Per interviews conducted, (4) of (4) staff state that C1 told them C1 did not wish to make/receive calls or visitations from one of their friends because they are causing C1 problems, however staff have not denied visits or calls made to C1. During the interview conducted with C1, C1 stated the staff are not retaliating against C1 and did not deny C1 visits or calls from their friend, but believes they will be upset if C1 talks to their friend and that is why C1 requested to not receive the calls/visitations. C1 stated to want to see and speak to their friend. This allegation is unsubstantiated.

Regarding allegation: Resident does not have access to a phone.
It is alleged that facility staff is screening telephone calls received at the facility and is not allowing C1 to receive calls from friends. (4) of (4) staff stated that the phone calls received are not screened and all clients are able to use the facility phone whenever they wish, without question. During the interview conducted with C1, C1 stated that C1 is allowed to use the facility phone and often calls their family, but not their friend due to a conflict they had. C1 states to not have their friend's telephone number, but if C1 received a call from said friend, C1 would like to speak to them. This allegation is unsubstantiated.

Regarding allegation: Facility disposed of resident's mail.
It is alleged that C1's mail received at the facility is being disposed without C1's knowledge. (4) of (4) staff denied the allegation and state that all correspondence received at the facility for the clients is distributed directly to them without question. During the interview conducted with C1, C1 denied the allegation and states to have received mail, including a holiday card from C1's friend which C1 showed to LPA and a check from that same friend, which C1 stated to have signed and cashed, as it was a gift for C1's birthday.

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.

Per California Code of Regulations, Title 22 and Health & Saftey Codes, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with house manager Darlene Carcoba and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2