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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802483
Report Date: 05/03/2022
Date Signed: 05/03/2022 02:27:03 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
04/25/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220425164647
FACILITY NAME:STEWART RESIDENTIAL HOMEFACILITY NUMBER:
197802483
ADMINISTRATOR:STEWART, MILLIEFACILITY TYPE:
735
ADDRESS:1591 SHIRLEY PLACETELEPHONE:
(909) 868-6524
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:4CENSUS: 4DATE:
05/03/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Facility Administrator/S-1TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Client is being physically abused while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial investigation for the above allegation. LPA met with Facility Administrator/S-1 and discussed the purpose of today's visit.

During today's visit, LPA obtained a Client Roster, Staff Roster and interviewed Staff #1 through Staff #3 (S-1 through S-3). LPA attempted to interview Client #1 (C-1) and Client #2 (C-2) and was unable to interview as C-1 and C-2 were not able to comphrehend the interview questions. LPA interviewed Client #3 (C-3). LPA was unable to interview Client #4 (C-4) as C-4 was at community based day program. LPA also reviewed client files and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.



Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
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-20220425164647
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: STEWART RESIDENTIAL HOME
FACILITY NUMBER: 197802483
VISIT DATE: 05/03/2022
NARRATIVE
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Allegation: Client is being physically abused while in care. During the course of this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3). LPA attempted to interview Client #1 (C-1) and Client #2 (C-2) and was unable to interview as C-1 and C-2 were not able to comphrehend the interview questions. LPA interviewed Client #3 (C-3). LPA was unable to interview Client #4 (C-4) as C-4 was at community based day program during this visit. Staff interviews revealed that clients are not being physically abused. Interviewed staff indicated C-1 has self-injurious behaviors and yells/screams loudly often. C-1's self-injurious behavior includes slapping self on face and head, punches self on thighs and stomach. Interviewed staff indicated C-1's behaviors are being tracked and reported to C-1's behaviorist. Additionally, interviewed staff indicated they are trained in Client Rights, Mandated Reporting and Zero Tolerance. Client interview revealed that staff do not physically abuse clients. Staff interviews, Client interview and reviewed documentation do not corroborate this allegation.

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 was conducted, a copy of this report and Appeal Rights were provided to Facility Administrator/S-1.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
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