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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320282
Report Date: 04/13/2023
Date Signed: 04/14/2023 06:03:01 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
04/06/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230406123315
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:
04/13/2023
UNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Sayra Ramos TIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Facility did not provide adequate supervision resulting in resident physically abusing another resident in care.
INVESTIGATION FINDINGS:
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On 04/13/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility, LPA was greeted by Direct Support Provider Sayra Ramos. LPA explained the purpose of today's visit is to investigate the allegation mentioned above.

The investigation consisted of the following: An interview with staff #1-#5 (S1-S5), client #1-#3 (C1-C3), and witnesses #1 #2 (W1-W2) about the incident and allegation mentioned above. Collateral visits were conducted at a day program and an affiliated licensed facility Service records were obtained for clients #1-#2 and other documents in association with this complaint. A tour of the facility was conducted.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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-20230406123315
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: 04/13/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility did not provide adequate supervision resulting in the resident physically abusing another resident in care.

It is alleged the facility failed to provide adequate supervision which resulted in a physical altercation between clients in care. According to the complaint client #1 (C1) was physically assaulted by client #2 (C2) and was bitten at the group home.

In an incident report received from the administrator staff #1 (S1) disclosed in written statement a group activity on 04/02/23. (C1) and (C2) were involved in a physical altercation which resulted in (C1) with injuries. (S1) reported that weekend group activities would involve clients from all (3) group homes. The clients in attendance included: (1) client from Acosta Family Home I, (2) clients from Acosta Family Home II, and (2) clients from Acosta Family Home III. During this activity, there were (3) employees on staff to provide care and supervision. (S1) reported that (C1) was sitting at the table doing activities, when suddenly (C2) sitting close by got upset and lunged and bit (C1) on the left forearm. (S1) stated that immediate medical attention was provided by (C1’s) primary physician and was provided with an antibiotic. (S1) stated she was not at the facility during the incident to supervise. An interview with (C1) disputes the location where the incident occurred, the staff members involved, the number of clients in attendance, and the number of injuries. (C1) claimed the incident with (C2) happened while outside the group home inside the van with only (C2) in the van. The van was parked outside Acosta Family Home III and staff #2 (S2) the only staff present went inside home with another client and left (C1) and (C2) unattended. (C1) claimed that (C2) punched (C1’s) face and bit (C1’s) on forearm and left scabs on left elbow and knee. (C1) unaware of what may have caused (C2) to react in this behavior and that no one witnesses the attack.

Interviews with staff #1, #2 and #3 (S1-S3) claimed the incident occurred while (C1) and (C2) both were at the dining table playing an activity. (S2) was in the kitchen preparing food, while (S3) was somewhere in the rear of the home preparing activities. Staff #4 (S4) who was also present on that day, stated the incident between (C1 and (C2) happened while watching television inside the living room with client #3 (C3). (C3) was interviewed and claimed to have not witnessed any altercations between clients. Interview with regional center service coordinator witness #1 (W1) and case manager witness #2 (C2) stated the incident was reported by (S1) and claimed that (C2) had a history of disruptive behavior but had no recent issues in months. (W1-W2) both verified that Acosta Family Home I & II are service level 2 and while Acosta Family Home III is classified as service level 4.

Evaluation Report continues on LIC-9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230406123315
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: 04/13/2023
NARRATIVE
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(C1) is a level 2 home that is classified with no major behavior problems and (C2) is a level 4 home with severely disruptive or self-injurious behavior. (S3) claimed as an Activity’s Director, she had no formal behavior training for adults with developmental disabilities. (S1-S4) all unaware of scabs on (C1’s) left elbow and knee. Although, (S1-S4) claimed that body checks are conducted daily all clients do not know when these wounds originated.

A review of (C1) and (C2) service records indicate both clients diagnosed with schizophrenia require continued supervision due to disruptive/aggressive social behaviors. Although (C2) is non-verbal, a collateral visit was conducted. The client was not available for an interview.

Based on interviews, observations, and supporting documentations, the facility failed to provide adequate supervision. There were lack of consistency or agreement with staff on where the incident occurred, unaware of the additional injuries on client, and socializing level 2 with level 4 clients in same activities revealed negligence in supervision. The preponderance of evidence standard has been met; therefore, the allegation of: " Facility did not provide adequate supervision resulting in the resident physically abusing another resident in care" is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview with Sayra Ramos and copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230406123315
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: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited
CCR
85075.4
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85075.4 Observation of the Client (a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

This requirement is not met as evidenced by:
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Licensee & Administrator shall read Title 22, Section 87075.4 “Observation of the Client” and submit a written statement to CCLD that you have read and understand this section. Establish a plan to maintain a body check registration. This plan is due to CCLD/El Segundo ASC Office by POC date of 04/14/23.
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Based on interviews, (C1) had scabs on left elbow and knee that was not included on the incident report and no staff had any knowledge of how the scabs had occurred. This volation posed an immediate health and safety risk to the clients in care.
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Type B
04/27/2023
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Licensee & Administrator shall read Title 22, Section 85078 “Responsibility for Providing Care and Supervision” and submit a written statement to CCLD that you have read and understand this section.
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Based on interviews and record analysis, (C1) and (C2) both diagnosed with behavior problems. (C1) is level 2 and (C2) is level 4 and the licensee should be cautious socializing different levels Licensee must follow client's needs and service plan. This violation poses a potential health and safety to clients in care.
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Establish a plan & work with HRC for supervision when different service levels are gathered. This plan is due to CCLD/El Segundo ASC Office by POC date of 04/27/23.
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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230406123315
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: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2023
Section Cited
CCR
80072(2)(3)
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80072 Personal Rights (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse...
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Licensee & Administrator shall read Title 22, Section 80072 “Personal Rights” and submit a written statement to CCLD that you have read and understand this section. Establish a plan for additional staffing to meet client's service needs. This plan is due to CCLD/El Segundo ASC Office by POC date of 04/27/23.
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This requirement is not met as evidenced by:
Based on interviews record analysis, LIcensee did provide adequate supervision that would haev prevented altercation between (C1) & (C2). This volation posed an immediate health and safety risk to the clients in care.
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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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5