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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801816
Report Date: 01/20/2022
Date Signed: 01/20/2022 03:35:18 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
01/13/2022 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220113161750
FACILITY NAME:MSJI HOME INCFACILITY NUMBER:
197801816
ADMINISTRATOR:INDIRA BHAVSARFACILITY TYPE:
735
ADDRESS:1324 JUANITA AVETELEPHONE:
(909) 592-6003
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 5DATE:
01/20/2022
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Ionie Taibo, DSPTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident is being harassed by another resident while in care.
Staff failed to provide a safe and comfortable environment for resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with caregiver,Ionie Taibo and explained the reason for the visit. Administrator, Indi Bhavsar was called and was interviewed over the phone. The initial complaint visit was conducted earlier today.

The investigation consisted of the following: During the initial visit, LPA interviewed three clients and three staff and a representative from San Gabriel/Pomona Regional Center. During the subsequent visit two more clients were interviewed.

The investigation revealed the following: It's alleged Client #1 (C1) is being harassed by Client #2 (C2) and staff fail to provide a safe environment. Allegedly C2 asked C1 to have sex with someone else. C1 was interviewed and indicated that clients in the home were just joking. C1 indicated that no one has touched him/her inappropriately and C1 reported feeling safe in the home.
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: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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-20220113161750
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: 01/20/2022
NARRATIVE
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C2 was interviewed and indicated that he/she was joking with another client when C1 over heard the conversation. C2 denies ever making any type of sexual comments to C1. Other clients interviewed did not have any knowledge of the situation. Staff interviewed deny ever knowing about the situation. San Gabriel/Pomona Regional Center representative also indicated that they had no knowledge of the allegations and also indicated that they talk to C1 regularly.

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

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2