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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320321
Report Date: 07/15/2023
Date Signed: 07/15/2023 09:38:05 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/26/2023 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230526150052
FACILITY NAME:ATAP RESIDENTIAL HOMEFACILITY NUMBER:
198320321
ADMINISTRATOR:WATERS, CORIFACILITY TYPE:
735
ADDRESS:11543 S. VAN NESS AVENUETELEPHONE:
(310) 292-8018
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:4CENSUS: 4DATE:
07/15/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jovan Hays, Care giverTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not want to give resident their medication.
Staff inappropriately handled resident.
Staff yelled at resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Jovan Hays, Care giver

The investigation consisted of following: Interviews and Record reviews. On 06/02/23, LPA Soto conducted an interview with the Administrator via telephone and S#1. The LPA requested copies of the following documents: File for C#1 (IPP, Physician's report, Mars for May 2023, and Incident Reports.) LPA received the following documents: Client and Staff rosters, Face sheets for C#1 - C#3, Physician's report for C#3. On 06/23/23, LPA Soto interviewed C#2, & C#3. C#1 was not available to be interviewed. Toured rooms 1 - 3, living room, dining room, and kitchen. On 07/03/23, LPA interviewed C#1 and conservator via telephone.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023
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-20230526150052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ATAP RESIDENTIAL HOME
FACILITY NUMBER: 198320321
VISIT DATE: 07/15/2023
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following.

Allegation 1 – Staff did not want to give resident their medication. Interviews with S#1 & S#2, communicated that they always give all the clients their medication. C#1 was not given their medication because they were away from facility and arrived at the facility late. Their time frame to be given their medication was passed, it was over 3 hours from the time they had to give C#1 their evening medication. S#1 also communicate that in their DSP training, it states that medication can be given an hour before or an hour after scheduled time, no later than those time frames. C#1 arrived at the facility 3 hours after C#1 scheduled evening medications. C#1 always acts out when anyone denies C#1 anything, C#1 begins to yell and bad mouth the individual that is denying C#1. C#1 does not like to be told no, C#1 will yell, scream, and say bad words when C#1 doesn’t get C#1’s way. They have advised C#1 and their conservator that if C#1 is not at the facility when C#1 ‘s medication needs to be given, they cannot give them to them at whatever time C#1 wants. They keep advising and reminding C#1 that it’s important for C#1 to be back to the facility in time to receive their medication. Facility also advised C#1’s service coordinator about C#1 medication not being given to C#1. S#2 communicated that C#1 was the phone with C#1’s conservator while C#1 was having their behavior and conservator was advised why they did not give C#1 their medication. Interviews with C#2 & C#3, communicated that they are always given their medication on time. They have never missed any medications and staff has never refused to give them their medications either. LPA reviewed the MARs for May 2023. On 05/20/23 C#1’s missed all C#1’s medications for that day (morning, afternoon, and evening.) Interviews conducted and records reviewed did not concur with above allegation.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230526150052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ATAP RESIDENTIAL HOME
FACILITY NUMBER: 198320321
VISIT DATE: 07/15/2023
NARRATIVE
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Allegation 2 - Staff inappropriately handled resident. Interviews with S#1 & S#2, communicated that they never mishandle any on their clients. C#1 always acts out when C#1 doesn’t get C#1 way. No staff tried or touched C#1, C#1 was just mad and angry C#1 was not getting their way. S#2 spoke with C#1’s conservator while C#1 was on the phone with them. Conservator knows S#2 did not touch or mishandle C#1. Interviews with C#2 & C#3, communicated that C#1 always create problems. C#1 always yelling and screaming and making things up. C#1 always blaming staff for everything, C#1 is annoying. C#2 also communicated that C#1 is not a good person, always making noise and making things up. Conservator communicated that they were on the phone at the time of the incident, but they know staff is nice and don’t think they touched C#1, conservator already knows how C#1 is. LPA reviewed C#1’s IPP dated 09/28/22, it states that C#1 tends to make false claims, is aggressive towards others, and has behavioral issues. The interviews conducted and records reviewed do not concur with the above allegation.

Allegation 3 - Staff yelled at resident. Interviews with S#1 & S#2, communicated that they never yell at clients. They would never yell or scream at them either. Conservator communicated that they know that staff did not yell at C#1, they were on the phone at the time of the incident and just heard staff speak loud but not yell at C#1. The interviews conducted do not concur with the above allegation.

Although the allegation 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

An exit interview was conducted with Jovan Hays, Care giver, and a hard copy of report was provided.


SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3