197800850-7-9-2023-28-AS-TVAO-CU3SA9-20230725134155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800850
Report Date: 07/08/2023
Date Signed: 07/09/2023 02:28:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/21/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230621112124

FACILITY NAME:	PAYNE CARE CENTER		FACILITY NUMBER:	197800850
ADMINISTRATOR:	WILLIAMS, LAVONIA PAYNE		FACILITY TYPE:	735
ADDRESS:	181 E. ARROW HIGHWAY		TELEPHONE:	(909) 506-4428
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	4	CENSUS: 3	DATE:	07/08/2023
		UNANNOUNCED	TIME BEGAN:	04:03 PM
MET WITH:	Staff #1		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide adequate supervision to resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit to deliver findings on 07/08/23 regarding the above allegation(s). LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit. arrived shortly after to assist in physical plant tour.

The investigation consisted of the following: Initial complaint investigation was conducted on 6/30/23 by LPA Ramirez. LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 interviews (S1), Client #1- 2 interviews (C1 – C2), C1 Face sheet, C1 Admissions Agreement, C1 Individual Program Plan (IPP) dated 7/12/21, facility “Sign-in/Sign-out” sheet for the months of May & June 2023, Special Incident Report (SIR) dated 6/16/23 & 6/20/23, and physical plant tour.

See 9099-C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2023

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-20230621112124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PAYNE CARE CENTER	FACILITY NUMBER: 197800850
	VISIT DATE: 07/08/2023

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

The investigation revealed the following. Regarding Allegation(s): Staff did not provide adequate supervision to resident in care. It is alleged that facility staff failed to provide adequate care to C1 on 6/16/23, which resulted in C1 wandering off and missing for a few hours. C1 was accepted into the facility on 04/13/18. C1 did elope from C1’s day program during an outing on 06/16/23 around 1:30 pm. Facility staff from Payne Care center where not present during outing and where later notified at 1:45 pm that C1 had eloped from day program. Claremont police were notified on 6/16/23. Per C1’s IPP, C1 enjoys going shopping, watching TV and dining out. IPP indicated C1 is able to navigate the community independently when safe, however, C1 needs to sign out and return to facility (Payne Care Center). C1 has a history of eloping from facility and the facility has filed several missing person reports. C1 has a history of returning to the facility from elopement within a few hours to returning within three days. Physician’s Report for C1 indicates C1 may leave facility unattended. Facility “Sign-in/Sign-out” sheet for the month of May and June of 2023, revealed C1 would “sign-in” and “sign-out” of facility and some days and C1 would elope on others. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2