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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600558
Report Date: 04/03/2023
Date Signed: 04/03/2023 03:01:10 PM

Document Has Been Signed on 04/03/2023 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PALS EINDELIJK EL MONTEFACILITY NUMBER:
198600558
ADMINISTRATOR:GLORIA GALLEGOSFACILITY TYPE:
775
ADDRESS:11645 MCBEAN DR.TELEPHONE:
(626) 279-1064
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 60CENSUS: 37DATE:
04/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gloria GallegosTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and explained the reason for the visit.
The purpose of the visit is to follow up on the SOC 341 submitted by the facility in regards to staff slapping a client.
The initial visit was conducted on 02/02/2023 and included the following:
Interview was conducted with Program Manager Zeke Meza at 1:50 P.M.
Files for Client C1 and Client C2 were reviewed. ID page, IPP and Physician's Report for C1 were submitted.
ID page and Physician's Report were submitted for C 2.
File was reviewed for Staff S 1. Personnel Record for S 1 was submitted.
Interviews were conducted with Staff S 2 and S 3 at 2:30 P.M.
City Of El Monte Police Department Case # 23-003267 submitted at visit.
At today's visit Staff S 4 was interviewed. Attempt was made to interview Client C1 who is non-verbal and didn't respond to questioning and immediately left the interview room not wanting to be interviewed.
In regards to the SOC 341 submitted it was determined on interviews with staff that Staff S 2 and Staff S 4 both observed Staff S 1 smack Client C1 in the mouth with an open hand and that it was hard contact making a loud sound. Stated loud enough to make C 1's head go back. C1 had taken off her mask.
Also was stated that S 1 pushed C1's chair hard back into the cubicle.
Both S2 and S4 reported the incident immediately to their supervisor.
Based on interviews conducted and information gathered personal rights deficiency cited on 809 D.

Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/03/2023 03:01 PM - It Cannot Be Edited


Created By: Glenn Trueman On 04/03/2023 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PALS EINDELIJK EL MONTE
FACILITY NUMBER: 198600558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2023
Section Cited
CCR
82072(a)(3)

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Personal Rights
Each client shall have personal rights which include, but are not limited to, the following:
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning.
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The administrator will ensure each client shall have personal rights in which they are free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature. The administrator will retrain the staff about personal rights and will send the staff training log to LPA by POC due date.
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The requirement is not met as evidenced by:
LPA's interviews with staff that reported staff S 1 smacked Client C1 in the mouth with an open hand and that it was hard contact making a loud sound which posed an Immediate Health and Safety Risk risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023


LIC809 (FAS) - (06/04)
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