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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801689
Report Date: 04/16/2024
Date Signed: 04/16/2024 03:37:14 PM

Substantiated


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
08/24/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230824142053
FACILITY NAME:FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLEDFACILITY NUMBER:
197801689
ADMINISTRATOR:TAMARU FRANCISFACILITY TYPE:
735
ADDRESS:715 E. CHESTER ROADTELEPHONE:
(626) 858-1803
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY:6CENSUS: 6DATE:
04/16/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Monet ManningTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff physically assaulted resident which resulted in bruises
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation and for the purpose of rendering the finding. LPA met with Staff #1 Monet Manning (DSP) who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 08/25/23, LPA obtained copy of client's face sheet, Individual Program Plan (IPP), physician report and behavioral services for Annual positive support plan. LPA conducted a tour of the facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA also checked the hot water temperature in the facility which tested 118.0 degrees F which is within the Title 22 regulation. LPA did not observe any immediate health and/or safety concerns. On 9/28/23, LPA interviewed Client#2- #6 (C2-C6) and two staff (S2-S3). LPA also interviewed Staff#1 (S1) via telephone and Client#1 (C1) at the day program.

(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
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 3
Control Number 28-AS-20230824142053
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: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 197801689
VISIT DATE: 04/16/2024
NARRATIVE
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The investigation revealed of the following: Allegation “Staff physically assaulted resident which resulted in bruises.” It is alleged that on 8/24/2023, C1 pulled down their shirt and showed their day program staff two bruises on their chest and stated that S1 hit them at their home facility. According to the interviews with staff and clients, four out of six clients did not witness the incident. One client reported hearing some commotion in the background on the day of the alleged incident, however, did not see what happened between C1 and S1. No other staff witnessed the incident. During interview, S1 denied physically assaulting C1 and reported that on the day of the incident, C1 refused to pick up their clothes from the floor after being asked by S1 to do so. S1 indicated that C1 suddenly stood up in front of him and charged at him aggressively with their fist clenched. In alleged self-defense, S1 used both hands to push C1’s chest to force him onto his bed to prevent being attacked. C1 landed in the sitting position on their bed and the incident did not escalate into anything else. Law Enforcement was contacted and a police report was filed. Per information and documentation obtained, C1 does not have a history of aggression.

Based on LPAs observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 is being cited on the attached LIC 9099D.



***An immediate Civil Penalty of $500.00 is being issued today, due to staff physically assaulted resident which resulted in bruises. Refer to LIC 421IM***

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(A) and may be assessed at a later date.

Exit interview conducted with Staff. A copy of the report and appeal right was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230824142053
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: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 197801689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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The administrator will ensure the staff understand each shall have personal right which include but not limited to to be free from corporal or unsusal punishment...etc
The administrator will retrain the staff with personal right and send the staff training log to LPA by POC due date.
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The requirement was not met as evidenced by LPA observation and interviewed conducted which S1 in alleged self-defense, S1 used both hands to push C1’s chest to force him onto his bed to prevent being attacked. C1 landed in the sitting position on their bed and the incident did not escalate into anything else which posed an immediate risk to client's in care.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3