198600312-8-9-2022-28-AS-MVAO-CHDR88-20220817124732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600312
Report Date: 08/09/2022
Date Signed: 08/09/2022 10:29:05 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 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
10/29/2020 and conducted by Evaluator Elizabeth Ceniceros

COMPLAINT CONTROL NUMBER: 28-AS-20201029110244

FACILITY NAME:	KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER		FACILITY NUMBER:	198600312
ADMINISTRATOR:	CHAMU-NESTOR, FRANCISCA		FACILITY TYPE:	735
ADDRESS:	753 SOUTH MARIPOSA STREET		TELEPHONE:	(818) 843-2695
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY:	6	CENSUS: 5	DATE:	08/09/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator, Francisca Chamu-Nestor		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff handled resident in rough manner.

Staff is verbally abusive towards resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Emmeline Balboza, Lead Caregiver) and was later met by Administrator (A1: Francisca Chamu-Nestor). LPA/RA was allowed entry into the facility and spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the clients or staff have symptoms.

The purpose of this visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 11/05/202 (via telephone) with Administrator Chamu-Nestor due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros re-interviewed Administrator; and, Staff #1 (House Manager and Staff #2 (S2: Direct Support Professional) were both interviewed by LPA/RA. Upon entry to the facility, LPA/RA observed three (3) clients at the facility awaiting transportation to its adult day program. LPA/RA did not interview Client #1 (C1) or Client #5 (C5); as they were already picked up for

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Araceli Ramirez
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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-20201029110244

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: KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER	FACILITY NUMBER: 198600312
	VISIT DATE: 08/09/2022

NARRATIVE

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their adult day program at 8:55 a.m. LPA/RA attempted to interview Client #2 (C2), Client #3 (C3), and Client #4 (C4) - between 8:20 a.m. and 8:40 a.m; however due to their cognitive impairment, LPA/RA could not interview the clients due to their non-responsive answers to the line of questions. LPA/RA re-interviewed Administrator and interviewed Staff #1 (S1: House Manager, Emmeline Balboza) and Staff #2 (S2: Bobby Simbajon) between 8:45 a.m. and 9:25 a.m. LPA/RA reviewed Client #1's records and obtained copies of pertinent documents.

Regarding Allegation #1: this investigation revealed that Staff #1 (S1) happened to be changing Client 1's (C1) blouse to attend the adult day program and was speaking briefly with C1 as projected in S1's voice; but, S1 was not handling C1 in a rough manner. Based on interviews conducted, the majority did not observe or feel that S1 was handling C1 in a rough manner or observe C1 crying or screaming. Regional Center conducted an internal investigation on 11/02/20 and also found the allegation to be unsubstantiated.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF CARE: Staff handled resident in rough manner is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Client #1 (C1) was going to attend the adult day program; and, C1 was getting its blouse changed by Staff #1 (S1). It could have been a misunderstanding of the way S1 was projecting her communication to C1 in a firm manner. Based on interviews conducted, the majority did not observe S1 to be verbally abusive towards C1. Facility staff have not been observed to verbally abuse clients; but, he/she will speak briefly in his/her voice to the clients due to their challenging behaviors. Regional Center conducted an internal investigation on 11/02/20 and also found the allegation to be unsubstantiated. LPA/RA observed facility staff communicating to the clients (prior to their departure to the adult day program) during this subsequent visit.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff is verbally abusive towards resident is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator Francisca Chamu-Nestor.

SUPERVISORS NAME: Araceli Ramirez
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC9099 (FAS) - (06/04)

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