198600401-10-31-2022-28-AS-RORN-CL7NBW-20221115091946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600401
Report Date: 10/31/2022
Date Signed: 10/31/2022 02:14:14 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
10/25/2022 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221025185643

FACILITY NAME:	NELVILLE GUEST HOME - TOPEKA		FACILITY NUMBER:	198600401
ADMINISTRATOR:	DELA CRUZ, HERMINIA		FACILITY TYPE:	735
ADDRESS:	1570 EAST TOPEKA STREET		TELEPHONE:	(626) 798-1685
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	5	CENSUS: 3	DATE:	10/31/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	House Manager, Imelda Chan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility administrator yells at clients

INVESTIGATION FINDINGS:

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Licensing Program Analyst, (LPA) Bennette Pena conducted an unannounced complaint visit in order to render findings for the above allegation. LPA met with the House Manager, Imelda Chan and discussed the purpose of today's visit. LPA was also in contact with the Administrator over the phone.

The investigation consisted of the following: LPA obtained staff/resident roster, staff and client interviews, review of clients records, daily log notes (ID notes) and incident reports.
**********CONTINUATION ON LIC9099-C***********

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

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-20221025185643

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: NELVILLE GUEST HOME - TOPEKA	FACILITY NUMBER: 198600401
	VISIT DATE: 10/31/2022

NARRATIVE

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***This report was amended to correct the word perseverating. LPA initially typed persevering (typo) instead of perseverating, which was the word used by the Administrator.*****

Regarding the allegation: Facility administrator yells at clients

The investigation revealed the following: LPA interviewed five (5) staff (S1-5) and all of them denied the allegation. S1 stated that she does not go to Topeka often and did not yell at clients. S1 stated that she usually speaks with a loud voice and in a firm way so she can re-direct the client's behaviors. S1 also stated that she repeats what she says in a loud voice to emphasize the message. S1 stated an example with C1 where C1 was perseverating because of hamburger. S1 stated that she had to talk to him in a louder voice to explain what day it was and that it was not a scheduled day to get hamburger. S2-5 stated that they never heard or seen S1 yell at clients or the staff. LPA attempted to interview two (2) clients (C2-3) but both are nonverbal and could not answer the questions due to cognitive impairment. LPA was unable to obtain information regarding incident. One (1) client (C1) indicated that the Administrator yelled at him a lot but cannot say why he was being yelled at. C2 stated that the Administrator's name is 'Lady'. C1 also stated that he likes living in the facility and no complaints. LPA attempted to call another staff (S6) three times (3x) but was unable to return LPA's telephone calls. LPA reviewed client files, ID notes/Daily log notes and incident reports filed but no evidence could be found. LPA was unable to corroborate allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did nor did not occur, therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of the report was provided to the House Manager, Imelda Chan.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

LIC9099 (FAS) - (06/04)

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