197801816-12-5-2025-28-AS-WSHO-DPEVX2-20251216154848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197801816
Report Date: 12/05/2025
Date Signed: 12/05/2025 03:11:09 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
12/02/2025 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251202101803

FACILITY NAME:	MSJI HOME INC		FACILITY NUMBER:	197801816
ADMINISTRATOR:	INDIRA BHAVSAR		FACILITY TYPE:	735
ADDRESS:	1324 JUANITA AVE		TELEPHONE:	(909) 592-6003
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 4	DATE:	12/05/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	S1		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff do not ensure that resident has privacy while in care.
Staff are not allowing resident to have access to their funds while in care.
Staff are not ensuring that resident has access to their medication while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation visit on 12/05/2025 and delivered findings. LPA was met by Direct Support Staff (DSP) Staff S1 and explained the purpose of the visit. Administrator Indira Bhavsar arrived shortly thereafter.
The investigation consisted of the following: LPA requested and obtained copies of Resident Roster and Staff Roster.
Interviews were conducted with Staff#1-3 (S1-S3), Client #1- 3 interviews (C1 – C3), attempted interview of Client#4 (C4) who was unable to respond to questioning being non-verbal.
Interview was conducted with the Administrator, Client C1's Medical Specialist and Regional Center Representative.
Review of Client C1's file was reviewed and Copies of Client#1 (C1): Admission Agreement, Face sheet, Physician Report, Physician's Documentation and Individual Program Plan (IPP) were submitted.
In regards to the allegation Staff do not ensure that resident has privacy while in care, based on interviews conducted and information gathered Client C1 stated that at doctor's appointments staff with him

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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-20251202101803

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: MSJI HOME INC	FACILITY NUMBER: 197801816
	VISIT DATE: 12/05/2025

NARRATIVE

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will speak to the primary care doctor about his medical file.
Stated that afterwards he does get to talk and tell his end of things.
Said medical specialist comes to facility and they do communicate 1 on 1.
Client's C2 and C3 stated that staff are great and will assist and guide them when needed.
Said they always get to speak with the primary care doctor as does staff so they know how to guide them.
Administrator stated that staff does not stop client's from talking to the primary care doctor.
Said medical specialist comes to the facility 1x a month and it is 1 on 1.
Stated they respect client's privacy and if they ask staff to step out they will.
Staff S1 stated he has been here 15 years and always goes with Client C1 to the primary care doctor.
Said Client C1 always talks to the doctor and has never asked him to step out.
Staff S2 stated that staff do go with the client to the doctor and they both talk at the appointment.
Staff S3 stated that Client C1 does talk with the doctor at the appointment and has never asked for them to leave.
Medical Specialist stated that their meetings are always private and they both communicate with each other.
Based on the information obtained, the allegation is unsubstantiated. 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.

In regards to the allegation Staff are not allowing resident to have access to their funds while in care, based on interviews conducted and information gathered Client C1 stated that he does receive weekly amount of $10.
Client's C2 and C3 both stated that they get spending money each month and also have money from working.
Administrator stated that there is no extra money from Regional Center and SSI is coming from family.
Documentation was reviewed specifying $ amounts and receipts given for Client C1 from 05/2/25- 11/28/25.
Also documentation from the quarterly progress report was reviewed and it states P and I balance $0.
Stated $10 a week for Client C1 is provided from the facility.
Said Client's C2 and C3 do get P and I each month.
Staff all stated that Client C1 gets funds weekly and the other 2 clients have money from work and P and I.
Regional Center Representative stated that there is no wrong doing from the facility. Stated family of Client C1 is the payee and would receive any monies.

Based on the information obtained, the allegation is unsubstantiated. 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.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20251202101803

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: MSJI HOME INC	FACILITY NUMBER: 197801816
	VISIT DATE: 12/05/2025

NARRATIVE

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In regards to the allegation Staff are not ensuring that resident has access to their medication while in care, based on interviews conducted and information gathered it was revealed by the Medical Specialist for Client C1 that the patch was discontinued because Client C1 has also been smoking and that is too much nicotine and it interferes with other medications and is a safety concern.
Documentation dated 11/04/25 states discontinuation of Nicotine patch as patient continues to smoke cigarettes and may lower the effects of his medications .Document was signed by the primary care doctor and the medical specialist.
Client C1 confirmed that his medical specialist said to stop using the patch because of smoking cigarettes too.
Administrator stated that there are doctor's orders to discontinue the patch.
Said Client C1 was smoking cigarettes and had the patch and was having delusions and destructive behaviors.
Staff all stated that Client C1 put in an order to discontinue the patch because it was too much nicotine and was then a safety danger.

Based on the information obtained, the allegation is unsubstantiated. 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 conducted with Administrator Indira Bhavsar and copies of the report were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC9099 (FAS) - (06/04)

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