198600640-3-2-2023-28-AS-RORN-CPWLQP-20230314085753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600640
Report Date: 03/02/2023
Date Signed: 03/02/2023 03:29:53 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
02/10/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230210143109

FACILITY NAME:	KAISER SPECIALIZED RESIDENTIAL ROSEMEAD		FACILITY NUMBER:	198600640
ADMINISTRATOR:	MOHAMMED SHIRAZI		FACILITY TYPE:	735
ADDRESS:	1702 ROBIN LINDA LN		TELEPHONE:	(626) 927-9177
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	4	CENSUS: 3	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Mohammed Shirazi		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident sustained a black eye while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Mohammed Shirazi and explained the reason for the visit.
The purpose of the visit is to deliver the findings for the above allegation.
The initial visit was conducted on 02/15/2023 and included the following:
Resident and Staff Roster, Client Notes, Marks and Bruises Document and Special Incident Report (SIR) were submitted.
Client C 1's file was reviewed and Physician's Report, Emergency ID page and IPP were submitted.
Administrator and Staff S 1- S 5 were interviewed from 2:15 PM to 3 PM.
Staff S 4 was interviewed telephonically at 3:00 PM.
Client C1 was interviewed at 2:00 PM. Attempts were made to interview C 2 who was unable to respond to questioning and interview was ended.
In regards to the allegation Resident sustained a black eye while in care. based on interviews conducted and information gathered, Client C 1 stated that she had hurt her eye and when asked how it happened

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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-20230210143109

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: KAISER SPECIALIZED RESIDENTIAL ROSEMEAD	FACILITY NUMBER: 198600640
	VISIT DATE: 03/02/2023

NARRATIVE

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she responded that she fell at her mom and dad's house. When asked if staff had hit her or yelled at her she responded no.
Staff stated that they have to fill out a Mark and Bruise Document when they observe marks on a client.
Staff stated that there were no marks or bruises when she left to her parents house and she had been given a shower and moisturizer on her face.
All staff interviewed stated that there has never been any incidents of physical aggression between staff and C1 or client's and C1.
Stated that C1 may often be the aggressor and punches the air at times.
Staff stated that C 1 was checked when leaving to go to her mom and dad's house and staff always makes sure that her body is clean and inform parents.
Initial Program Plan (IPP) dated 01/12/2022 states the following behaviors are being tracked for C 1: behavioral outbursts, physical aggression, resistance non-compliance and verbal aggression.
Client notes state that C1 returned back to the facility on 02/04/2022 from her parents house and came to the facility with her dad and was cursing at him and tried to hit staff. It states that dad told her to go to her room and when she came to dinner shortly thereafter that is when the mark was first observed.
It should also be noted that the findings of the Eastern L.A. Regional Center's investigation was Unsubstantiated.

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.

An exit interview was conducted with Administrator.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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