198320073-5-23-2024-11-AS-MVAO-D5PUUU-20240528155407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320073
Report Date: 05/22/2024
Date Signed: 05/23/2024 08:18:50 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
05/14/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240514093833

FACILITY NAME:	INCLUSION SPECIALIZED PROGRAMS,LLC-WEST 130TH		FACILITY NUMBER:	198320073
ADMINISTRATOR:	COOK, DAVID		FACILITY TYPE:	738
ADDRESS:	4442 W. 130TH ST		TELEPHONE:	(626) 476-2341
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	4	CENSUS: 1	DATE:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	David Cook		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff hit resident.
Staff spoke inappropriately to resident.
Staff handled resident in a rough manner.
Staff does not treat resident with respect.

INVESTIGATION FINDINGS:

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On 05/22/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met Administrator, David Cook, and the purpose of today’s visit was explained.

During today’s visit, LPA toured the facility, interviewed Staff S1-S5, interviewed Client C1, and received documents pertinent to the investigation. LPA received and reviewed the following documents Resident Roster, Staff Roster, Resident Identification sheet, Resident Needs and Service Plan, Resident Individual Behavior Support Plan, Resident Monthly Client CCH Report, Individual Program Plan (IPP), Behavioral Assessment Report, and staff training logs.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 4

Control Number 11-AS-20240514093833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS,LLC-WEST 130TH	FACILITY NUMBER: 198320073
	VISIT DATE: 05/22/2024

NARRATIVE

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Allegation: Staff hit client
It is alleged the staff hit client on the head.
During record review, LPA reviewed the facility’s Zero Tolerance for Consumer Abuse Policy Service Provider Certification, Westside Regional Center Zero Tolerance Policy for Abuse or Neglect, and San Gabriel/Pomona Regional Center Zero Tolerance Policy (SG/PRC & Facility) Documentation signed by all staff.
During interviews with Staff S1-S5, were asked if they have or observed staff hit a client, five (5) out of five (5) stated they have not hit a client nor have they observed another staff hit a client.
During an interview with Client C1, was asked if staff have hit them, Client C1 stated staff have not hit them. Additionally, C1 stated they posted some things on social media and that what they posted was not true and it did not happen.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff spoke inappropriately to client

It is alleged the staff call the client names.
During record review of staff training, LPA observed Staff received a training regarding how to communicate with clients, the trainings received were Skills for Effective Communication on 02/22/24 and Building Bridges: Language and Cultural Considerations in the Community Crisis Home on 02/02/24.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20240514093833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS,LLC-WEST 130TH	FACILITY NUMBER: 198320073
	VISIT DATE: 05/22/2024

NARRATIVE

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During interviews with Staff S1-S5, were asked if they have or have observed staff speak to clients inappropriately, five (5) out of five (5) stated they have not nor have they heard staff speak inappropriately to clients.
During and interview with Client C1, was asked if staff speak inappropriately to them, Client C1 stated they speak nicely to them and they have not been called any names by staff.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff handled resident in a rough manner

It is alleged the staff are rough with client.
During record review LPA observed staff received training in Non-Violent Crisis Intervention, Client’s Behavior Plan, CPI Evasion Techniques, Client’s Intervention Behavior Support Plan, and Conflict Resolution.
During interviews with Staff (S1-S5), were asked if they have or observed staff handling Clients in a rough manner, five (5) out of five (5) stated they have not nor have they observed staff handle Clients in a rough manner. Additionally, staff stated if a client is exhibiting aggressive behavior they block with open hands and do not hold clients in any way.
During an interview with Client C1, was asked if staff have handled them in a rough manner, C1 stated they have not been handled them in a rough manner.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240514093833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS,LLC-WEST 130TH	FACILITY NUMBER: 198320073
	VISIT DATE: 05/22/2024

NARRATIVE

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preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff does not treat resident with respect

It is alleged the staff do not treat client with respect and are not nice to them.
During record review, LPA observed staff received training in Ethics and Responsibilities, and Person-Centered Care.
During an interview with Staff (S1-S5), were asked if they treat clients with respect, five (5) out of five (5) stated they treat residents with respect.
During an interview with Client C1, was asked if staff treat them with respect, Client C1 stated the staff treats them with respect, that they love the staff, and they have great personalities.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Administrator, David Cook and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

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