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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198202830
Report Date: 08/17/2023
Date Signed: 11/22/2023 08:20:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2023 and conducted by Evaluator Antonine Richard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230810112113
FACILITY NAME:GRACE CARE CORPORATIONFACILITY NUMBER:
198202830
ADMINISTRATOR:RUTH AARONFACILITY TYPE:
775
ADDRESS:2111 W. SLAUSON AVENUETELEPHONE:
(323) 295-6590
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:75CENSUS: 49DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Thomas AaronTIME COMPLETED:
04:52 PM
ALLEGATION(S):
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Staff assault client.
INVESTIGATION FINDINGS:
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This is an Amendment of the report delivered on 08/17/2023, to remove private information. This Amendment does not change the findings of this investigation.

08/17/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint investigation at above facility. LPA arrived at the facility and was greeted by the receptionist. LPA explained the purpose of visit was for the allegations listed above and was allowed entry to the facility to meet with Licensee Thomas Aaron.

The investigation consisted of the following: LPA toured the facility, reviewed facility files and interviewed the Supervisor, and 2 Clients (C1-C2) out of 49 clients. and 5 staff (S1-S6) out of 24 staff. Facility files were reviewed and copies of Staff roster, Clients Roster, Special incident report for all vendors and other documents in association with the allegations were received.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
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 5
Control Number 11-AS-20230810112113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198202830
VISIT DATE: 08/17/2023
NARRATIVE
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The investigation revealed the following:

Allegation #1 Staff assaulted Client. LPA Antonine Richard interviewed the alleged victim. client C1, that the staff S6, pushed C1 from getting inside van. LPA Richard interviewed (S1). S1, confirmed staff (S6), did pushed C1 from getting inside the Van. Licensee Thomas Aaron stated on "07/10/2023, he found out about the incident, and suspended staff S6". The licensee stated "after the internal investigations were completed, he decided on 07/12/2023 to terminate staff S6".
Records reviewed from staff records revealed that staff S6 was terminated on 07/12/2023 due to the physical and verbal abuse of client C1 while in care.

Based on the information collected, an inspection of the facility, observation, and 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 8 are being cited on the attached LIC 9099-D


An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Thomas Aaron.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20230810112113

FACILITY NAME:GRACE CARE CORPORATIONFACILITY NUMBER:
198202830
ADMINISTRATOR:RUTH AARONFACILITY TYPE:
775
ADDRESS:2111 W. SLAUSON AVENUETELEPHONE:
(323) 295-6590
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:75CENSUS: DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Thomas AaronTIME COMPLETED:
04:52 PM
ALLEGATION(S):
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9
Staff verbally abused client.
uncleared staff were working at the facility.
Facility failed to report an incident.
INVESTIGATION FINDINGS:
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08/17/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint investigation at above facility. LPA arrived at the facility and was greeted by receptionist. LPA explained purpose of visit was for the allegations listed above and was allowed entry to the facility to meet with Licensee Thomas Aaron.
Allegation 2 - Staff verbally abused client .LPA Interviews with S#1 – S#5, staff stated they have never verbally abused clients at any time for any reason. Sometimes they speak in a loud voice to client because some clients are hard of hearing. Interviews conducted with C1- C2, communicated that they have never been verbally abused at by staff or anyone else. The staff is nice not mean. The interviews conducted do not concur with the above allegation.

Allegation 3 - Uncleared staff were working at the facility. Licensee Thomas Aaron Stated I would never allow anyone working at this facility without a finger printed clearance. LPA have compared the Licensing Information System (LIS) list with the personel records of every staff on the LIS are cleared. The record review conducted do not concur with the above allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230810112113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198202830
VISIT DATE: 08/17/2023
NARRATIVE
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Allegation 4 - Facility failed to report an incident. Based on observation, Interviews conducted and record review, the Licensee did fax a copy of the Special Incident Report for all Vendors on 07/11/23. The interviews conducted do not concur with the above allegation.

Based on observation, interviews, and record reviews the 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. according to California Code Regulation Title 22 no deficiency issued.

An exit interview was conducted with the licensee Thomas Aaron a copy of the report was provide.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230810112113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198202830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
82165(a)(d)(3)
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The licensee shall ensure staff who are participate in approve or providing care and supervision. The licensee shall provide care and supervision as necessary to meet the clients needs. Alternative methods of handeling aggressive and assaultive behavior.
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Licensee is to review Title 22 Regulation section 82165 (a)(d)(3) for how to train staff at the Day Program. Licensee did terminated the staff after the incident. Licensee will Submit a plan of correction to LPA via email
Antonine.Richard@dss.ca.gov. Phone(323)
516-4092
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The facility did not provide care and supervision to client #1, while in care. when the staff assaulted client while at the day program
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5