198600640-3-2-2023-28-AS-TVAO-CQVVGK-20230414162538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600640
Report Date: 03/02/2023
Date Signed: 03/02/2023 12:55:34 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
02/23/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230223090811

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:	08:56 AM
MET WITH:	Victorina Tongco - Direct Support Staff		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Victorina Tongco Direct Support Staff and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of staff and client roster, conducted interview with staff #2(S2), and client #2(C2). LPA conducted interviews with administrator (S1), Staff #3(S3), #4(S4), S5(#5), and #6(S6) over the phone. LPA contacted client's #1(C1) over the phone and conducted a video call with C1. LPA contact quality assurance person from the East Los Angeles Regional Center (ELARC). LPA requested the following documents; face sheet for C2,C3,C4, C1's physician report, identification and emergency sheet, individual personal plan (IPP), incident report dated 2/2/23 and , caregiver's schedule for January/February 2023.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
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-20230223090811

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

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff handled resident in a rough manner. It is alleged client #1(C1) is being pushed by staff member of facility. Interviews with clients revealed, 2 out of 2 clients were unable to be interview due to cognitive skills. Interviews Administrator revealed a staff was out on leave due to an allegation from 1/27/23 regarding C1 stating S6 had pushed C1. Interviews with staff revealed 5 out of 5 staff interview stated that they have not observed or heard staff treating clients in a rough manner or had pushed C1. ELARC investigated, the allegation and did not have evidence to support the allegation. Documents review revealed an incident report dated 2/2/23 was submitted to the department regarding a fall sustained by C1 on 1/27/23. IPP dated 10/14/21 and annual behavioral report dated 1023/22 noted C1's history of behaviors.

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.

Exit interview was conducted with Victorina Tongco Direct Support Staff and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
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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