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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801816
Report Date: 03/05/2024
Date Signed: 03/05/2024 06:51:25 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
02/26/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240226163207
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: 4DATE:
03/05/2024
UNANNOUNCEDTIME BEGAN:
07:29 AM
MET WITH:Administrator Indira BhavsarTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff yells at residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez and Christian Guitierrez, conducted initial complaint investigation visit on 03/05/2024 and delivered findings. LPA’s were met by Direct Support Staff (DSP) Rhodora Cabrera and explained the purpose of the visit. Administrator Indira Bhavsar arrived 45 minutes later to assist with tour.

The investigation consisted of the following: LPA’s requested and obtained copies of Resident Roster, Staff#1-2 interviews (S1-S2), Copies of Staff#1&3 (S1 & S3) Application of Employment, Client interviews#1- 2 interviews (C1 – C2), attempted interview of Client#3 (C3), Copies of Client#1 (C1): Admission Agreement Face sheet, Physician Report dated 04/17/2023, Antecedent-Behavior-Consequence Data Sheet (ABC) for various days in the month of February 2024, Facility staff progress notes for various dates in February of 2024, 1st Quarterly Progress Report dated January 2024, and physical plant tour.

See 9099-C for continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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-20240226163207
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: MSJI HOME INC
FACILITY NUMBER: 197801816
VISIT DATE: 03/05/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation: Staff yells at clients in care- It is alleged facility staff yelled at C1. Two (2) out of the two (2) staff interviewed deny the allegation. Interview with Client#2 (C2) revealed, C2 overheard staff#3 (S3) yelling at C1. C2 revealed they overheard C1 and S3 yelling at each other and C2 could hear the yelling from their bedroom. Review of facility daily progress notes and indicated on or around 2/23/24, staff documented C1 became agitated that the van pick up for day program had not yet arrived and requested staff call to get an ETA. According to staff, C1 began cursing and yelling at staff. Although staff denied yelling back at C1, C2 was in their bedroom and confirmed to LPA’s that S3 did yell back at C1. LPA’s attempted to interview client#3 (C3), due to cognitive impairments, LPA’s were unbale to conduct interview. Client#4 (C4) was out in the community during the visit and LPA’s were unable to interview. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency is being cited today. Exit interview was conducted and a copy of this report, 809-D and appeals was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240226163207
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: MSJI HOME INC
FACILITY NUMBER: 197801816
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2024
Section Cited
CCR
80072(a)(1)
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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: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidence by:
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Licensee will re-train staff on this regulation and re-train staff on clients IPP and on how to redirect behavriors according to IPP. Proof of re-training must be received via email by 3/19/24.
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Interviews with clients confirmed staff (S3) yelled at client while 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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3