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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320282
Report Date: 02/08/2023
Date Signed: 02/08/2023 10:48:15 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
01/30/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230130150937
FACILITY NAME:ACOSTA FAMILY HOME IIFACILITY NUMBER:
198320282
ADMINISTRATOR:ACOSTA, ASHLEYFACILITY TYPE:
735
ADDRESS:1811 EAST ABILA STREETTELEPHONE:
(310) 604-8740
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:4CENSUS: 4DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ashley AcostaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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On 2/08/23 at 8:50 am, Licensing Program Analyst (LPA) Perry Scott conducted a complaint visit to the above facility. LPA was met by administrator, Ashley Acosta, and the purpose of the visit was explained.

The investigation consisted of the following:

On 02/08/23 at 9:30am, LPA interviewed the administrator, Ashley Acosta staff 1 (S1) and Staff 2 and clients 1-2. LPA obtained copies of resident/staff rosters, admission agreement, face sheet, ID/Emergency information, behavioral assessment and support plan, physicians report, and SIR’s. LPA conducted a tour of the physical plant, which consisted of common areas, client rooms, and storage areas.

The investigation revealed the following: Allegation: Staff handled resident in a rough manner.

Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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 3
Control Number 11-AS-20230130150937
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: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282
VISIT DATE: 02/08/2023
NARRATIVE
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The investigation revealed the following: Allegation: Staff handled resident in a rough manner.

LPA interviewed the administrator about the allegation. She stated that she spoke to both C1 and S3 about the incident and it was verified by both parties. The administrator fired S3 the same day due to a zero-tolerance policy.

On 02/08/23, LPA interviewed S2, and she corroborated that C1 was handled roughly by S3. LPA could not interview S3 because he has since been fired by the administrator.

On 02/08/23 LPA interviewed C1-C2, and both corroborated the incident that C1 was handled roughly by S3.

Based on LPAs interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. The staff did handle the resident in a rough manner which poses a risk to residents in care. Deficiencies cited under California Code of Regulations, Title 22, Division 6, and Chapter 1 & 6 are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of the report was given to the administrator, Ashley Acosta.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230130150937
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: ACOSTA FAMILY HOME II
FACILITY NUMBER: 198320282
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
80072(a)(1)(2)(3)
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Each client shall have personal rights which include, but are not limited to, the following:To be accorded dignity in his/her personal relationships with staff.. To be accorded safe, healthful and comfortable..To be free from corporal or unusual punishment, infliction of pain, humiliation..This requirement is not met as evidenced by:
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Licensee shall provide additional training to staff regarding personal rights and ensure future personal rights violations will not occur and provide proof to the LPA that the training was completed by providing a training log with the dates and those in attendance to clear the POC by 02/10/23.
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Based on interviews and record review, the licensee did not ensure that the staff was trained properly. Their behavior posed a risk to the clients while in their care because Client 1 was handled in a rough manner by staff.
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Note: Staff has since been fired due to his actions on 01/27/23.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3