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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198202981
Report Date: 11/09/2022
Date Signed: 11/21/2022 08:51:14 AM

Unsubstantiated


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
11/01/2022 and conducted by Evaluator Don Senaha
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221101111913
FACILITY NAME:EMILY'S HOME VFACILITY NUMBER:
198202981
ADMINISTRATOR:EMELINA MARQUEZFACILITY TYPE:
735
ADDRESS:19203 CAMPAIGN DRIVETELEPHONE:
(310) 378-3669
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:6CENSUS: 4DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Licensee - Emlina MarquezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff hit resident.
INVESTIGATION FINDINGS:
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On 11/09/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. LPA was greeted by caregiver Carol Sanders at the door. Today’s complaint investigation was conducted with caregiver Carol Sanders and later joined by Licensee Emelina Marquez.

The investigation consisted of the following: LPA requested resident roster, staff roster and other service documents. LPA interviewed Licensee, staff (S1-S2) and witness (W1-W2). LPA was unable to interview clients (C1-C4) due to medical reasons.

A plant inspection of the facility was conducted.

There were no deficiencies found during any visits.

Investigation revealed:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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 11-AS-20221101111913
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: EMILY'S HOME V
FACILITY NUMBER: 198202981
VISIT DATE: 11/09/2022
NARRATIVE
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Allegation: Staff hit resident.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. LPA observed no visible injuries on clients (C1-C4) during visit. Licensee, staff (S1-S2) and witness (W1-W2) stated there are no concerns or have ever witnessed staff being physical or abusive towards clients (C1-C4). Licensee, staff (S1-S2) and witness (W1-W2) stated there are no issues or have witnessed staff speaking inappropriately to clients (C1-C4). LPA obtained and reviewed trainings for staff regarding abuse and clients rights. LPA reviewed incident reports and did not see any incidents reporting staff hitting residents. LPA did obtain and reviewed incident report for staff (S3) who was terminated recently due to stolen device from staff (S4). Licensee stated staff (S3) specified staff (S3) would “be calling licensing” to report the facility upon termination.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Licensee Emelina Marquez and a hard copy was provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2