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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600140
Report Date: 08/15/2024
Date Signed: 09/06/2024 01:47:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2024 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240730082307
FACILITY NAME:SALEM HOMEFACILITY NUMBER:
198600140
ADMINISTRATOR:DELORES BERINTIFACILITY TYPE:
735
ADDRESS:4122 KIMA CTTELEPHONE:
(562) 634-1256
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:4CENSUS: 3DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Zoila Nava - Direct Support ProfessionalTIME COMPLETED:
04:38 PM
ALLEGATION(S):
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Staff hit resident
Staff pushed resident
Staff did not allow resident to possess personal belongings
INVESTIGATION FINDINGS:
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***This is an amended report which supersedes the original report dated 08/15/2024. The report was amended to correct information on the narrative. Corrected information does not change the findings. Complaint remains unsubstantiated. LPA Mora redelivered amended report and obtained signature on 09/06/2024.***

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Zoila Nava (Direct Support Professional) and explained the reason for the visit.

The investigation consisted of the following: On 08/08/2024, LPA obtained copies of the staff and client roster. LPA interviewed the Residential Care Manager, Staff 1 - Staff 3 (S1 - S3), Client 2 (C2), and Regional Center Representative. During today's visit, LPA Mora interviewed Client 1 (C1) via telephone, Client 3 (C3) and Client 4 (C4).

The investigation revealed the following: regarding the allegations "staff hit resident", "staff pushed resident" and "staff did not allow resident to possess personal belongings", it is alleged that on 07/29/2024 S1 pushed, hit and took C1's backpack away from C1. (Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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 2
Control Number 28-AS-20240730082307
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SALEM HOME
FACILITY NUMBER: 198600140
VISIT DATE: 08/15/2024
NARRATIVE
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The Administrator is currently out of the country and the Residential Care Manager is charge of the facility. The Residential Care Manager stated that she is unaware of these allegations that occurred on 07/29/2024, but C1 did accused S1 of hitting and pushing C1 on 06/23/2024. The Residential Care Manager and Regional Center conducted their own investigations and unsubstantiated the allegations. After this incident, it was determined that C1 should be moved to another facility and on 08/05/2024 C1 moved. S1 was also unaware of these new allegations and denied hitting, pushing or taking C1's belongings. S1 stated that there was an investigation back in June 2024 regarding S1 hitting C1 and S1 was found innocent. C1 stated that S1 hit C1's shoulder, pushed C1 and also took C1's backpack, and this happened in the living room in front of all the other clients. The other clients denied the allegations and stated that S1 did not hit, push or take away C1's belongings. Regional Center Representative stated that an investigation was conducted in June 2024 regarding S1 hitting C1 and they unsubstantiated that allegation.

Although the allegations 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.

Exit interview held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2