198600229-7-27-2023-28-AS-FFIS-CVVU9B-20230921152252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600229
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:41:22 PM

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 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
07/20/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230720083459

FACILITY NAME:	CLAYTON COTTAGE GALEN		FACILITY NUMBER:	198600229
ADMINISTRATOR:	CARYN M. CLAYTON		FACILITY TYPE:	735
ADDRESS:	1248 GALEN STREET		TELEPHONE:	(626) 357-7586
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	6	CENSUS: 5	DATE:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver-Obinna Nwamadu		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are not providing adequate care and supervision to the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an initial 10 day complaint investigation for the allegation listed above. LPA met with Caregiver Obinna Nwamadu and discussed the purpose of the visit. Obinna called Assistant Administrator Cameron Clayton and LPA was on the telephone call and discussed the purpose of today's visit.

The investigation consisted of the following: LPA Calderon interviewed the Assistant Administrator, staff #1, #2 and #4 (S1,S2 and S4), attempted to interview staff #3(S3), LPA interviewed clients #1-#5 (C1-C5), LPA attempt to interview Via telephone San Gabriel/ Pomona Regional Center Service Coordinator, LPA attempt to interview two of C1's relatives via telephonically, relative #1 of C1 was an attempt interview and C1's relative #2 was interviewed. LPA requested a copy of the staff and client roster. LPA collected C1's Facesheet, Physician's report, most recent psychiatry, dentist, and medical report, C1's IPP Signature page, Ipp Status Report, IPP dated 5/25/22, Special Incident Reports (SIR) for 5/17/23, Police Report and SIR for 5/15/23, SIR for dates 6/3/23, 6/4/23, 6/26/23,6/27/23,6/28/23. 7/2/23, 7/4/23 and Two reports for 7/11/23. (Continuation on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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-20230720083459

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLAYTON COTTAGE GALEN	FACILITY NUMBER: 198600229
	VISIT DATE: 07/27/2023

NARRATIVE

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LPA collected C2, C3,C4's Facesheet, reports for : medical, pediatrist, dental and psychiatrist, and IPP Signature Page. C4's SIR dated 5/15/23 and C5's Facesheet, reports for medical, pediatrist, dental, and psychiatrist, and physical exam.

Regarding allegation: Staff are not providing adequate care and supervision to the residents. Based on observations, record review and interviews during today's visit the following was revealed. It was stated during Interview with Assistant Administrator Cameron that staff are providing adequate care and supervision by having frequent visits to see the doctor, dentist and psychiatrist. Staff are always present at the facility, and clients are supported by staff. Cameron stated C1's behaviors are communicated with C1's doctors, psychiatrist, and regional center service coordinator and there is a plan in place. It was stated in Interviews with Staff S1,S2, S4 and S5 that staff are providing adequate care and supervision by attending to clients needs, assisting with activities of daily living, providing medical assistance based on clients needs, being present at the facility, providing assistance, having 2-3 staff per shift when all clients are present. Based on interviews with Cameron, S1, S2, S4 and S5 it is stated that police are called when client(s) display aggressive and violent behavior towards clients and staff members providing dangerous behaviors causing a threat and harm to personnel's at the facility. Based on record review all clients seek medical professional attention and facility report to appropriate agencies and personnel's like: medical professionals, client guardian's, law enforcement, regional center and licensing. Based on interviews, observations, and record review staff are providing adequate care and supervision the clients in care.

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore the allegation is UNSUBSTANTIATED.

There are no deficiencies cited. Exit interview conducted with Caregiver Tina Hardy.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

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