198600156-7-7-2023-28-AS-LHIS-CTPNVH-20230713104759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600156
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:25:50 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
07/06/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230706105156

FACILITY NAME:	KAISER SPECIALIZED RESIDENTIAL GLENDORA		FACILITY NUMBER:	198600156
ADMINISTRATOR:	AGNES AGUILA		FACILITY TYPE:	735
ADDRESS:	1620 AVON PLACE		TELEPHONE:	(626) 857-1827
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	4	CENSUS: 4	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	08:11 AM
MET WITH:	Agnes Aguila, Administrator		TIME COMPLETED:	03:37 PM

ALLEGATION(S):

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Staff threatened resident
Staff push the client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez conducted a complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Agnes Aguila and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of the following: Client Roster, Staff Roster, Special Incident Report submitted to CCL (dated 07/05/2023), C1 behavior notes (dated 07/02/2023), C1 Individual Program Plan (dated 12/07/2022) and Behavior Treatment Plan (dated 12/20/21), reviewed of C1)file, interviewed Administrator, Agnes Aguila S#1 (S1), 4 staff (S#2- S#5), 3 clients (C#1-C#3), LPA was unable to interview C4 (C#4) LPA attempted to contact Regional Center Service Coordinator, and Behaviorist without success.
Allegation: Staff threatened resident. It is alleged that S4 and S5 told C1 that they were going to put C1 on the ground.
(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230706105156

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: KAISER SPECIALIZED RESIDENTIAL GLENDORA	FACILITY NUMBER: 198600156
	VISIT DATE: 07/07/2023

NARRATIVE

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Allegation: Staff threatened resident. It is alleged that S4 and S5 told C1 that they were going to put C1 on the ground.

The investigation revealed the following:

LPA interviewed five staff and all five staff denied the allegations. LPA interviewed three clients and all three did not collaborate the allegations. C1 stated that no one threatened C1 and that C1 made up allegation because C1 was upset that aunt did not pick C1 up for holiday. C1 told LPA that she lied.

Allegation: Staff push the client It is alleged that S2 pushed C1 causing C1 to fall on the ground.

The investigation revealed the following:

According to staff #2 (S2) client 1 (C1) was speaking to C1 aunt at approximately 4:00PM and became upset when C1 was informed by C1 aunt that aunt was not picking C1 up for the fourth of July Holiday. S2 stated that S2 witness C1 getting upset and agitated. C1 contacted administrator shortly after C1 call with aunt and asked Administrator if Janice (Behaviorist) could take C1 to C1’s aunts home. Administrator explained that was not possible as Janice is behaviorist, not staff. S2 stated C1 began to disrupt the home and other clients with C1 behavior. S1 stated that that C1 was upset when C1 called Administrator. Administrator stated that C1 has history of making up allegations. S2 stated that C1 stated over and over that C1 was going to slam C1 door because C1 was upset. C1 and C4 were in a verbal dispute during this time and staff was able to defuse the situation without incident. S2 stated that S4 and S5 attempted to redirect C1. S2 denied pushing C1 and S4 and S5 denied the allegation occurred. S3 stated S3 was not on duty on day of incident. C1 stated that C1 made up the allegations because C1 was upset that C1 aunt didn’t pick C1 up for the holiday. C1 told LPA that C1 lied about the allegations and that they never happened. C1 stated no one pushed C1. Other residents interviewed, 2 of 4 could not collaborate the allegation and stated that staff is nice to them. LPA was unable to interview C4. S4 stated police was contacted by day program on July 5^th, 2023, and (Officer Rodriguez) conducted interviews with S4 and C1 via phone. C1 stated she told police C1 lied and made-up allegations. No follow up visit or call has been made by police department.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held. A copy of the report and appeal rights were provided to Administrator Agnes Aguila..

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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