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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600754
Report Date: 05/23/2025
Date Signed: 05/23/2025 03:55:32 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
05/21/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250521144642
FACILITY NAME:CENTER FOR BEHAVIORAL CHANGE IVFACILITY NUMBER:
198600754
ADMINISTRATOR:PIGGEE, JASON A.FACILITY TYPE:
735
ADDRESS:2755 MIRANDA STREETTELEPHONE:
(626) 839-5115
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY:4CENSUS: 4DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Raphael Afolabi, DSPTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Client was injured by staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit telephonically to Administrator Jason Piggee and DSP staff Raphael Afolabi.

The investigation consisted of: A physical plant inspection, record review, and interviews with staff (S1-S4) and client (C1- C3). Copies of C1's Face Sheet, IPP, 2025 Progress Report, LIC 500 Personnel Report, and client roster were obtained.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20250521144642
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: CENTER FOR BEHAVIORAL CHANGE IV
FACILITY NUMBER: 198600754
VISIT DATE: 05/23/2025
NARRATIVE
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Allegation: Client was injured by staff. It is alleged that on a recent Saturday or Sunday evening, client (C1) was scratched by staff (S1) in the neckline. It was reported that S1 barged into C1's room and purposely scratched the client for talking about their favorite football team. Picture evidence was obtained. The scratch is minor, approximately 1 inch without sign of infection. A total of three (3) clients were interviewed. Client (C1) stated that S1 scratched them when nobody was around because the staff likes to take out their anger on the client. Two (2) other clients were interviewed. They confirmed C1 has a scratch in the neckline area, but stated they did not see S1 scratch the client. A total of four (4) staff were interviewed, of which all denied the allegation. Staff stated that C1 has aggressive behaviors, past history of story fabrication and self-injurious behaviors. During the last week staff witnessed C1 injure themselves arm by purposely hitting the door knob. According to staff interviews, S1 prompted the client to shave, but the resident refused and began insulting staff because they got upset about staff reminders. Based on record review, client (C1) is developmentally disabled with history of noncompliance with hygiene tasks, history of story fabrication, property destruction, verbal aggression, and resistive behaviors. The findings indicate that C1 has recently had resistive behaviors when prompted to shave, recent self-injurious behaviors, and there has been an increase in insults aimed at staff. There is insufficient evidence to corroborate the allegation.

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 DSP Raphael Afolabi. A copy of the report was issued electronically to Administrator Jason Piggee.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2