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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600930
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:58:56 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
07/20/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210720163547
FACILITY NAME:VICTORIA RESIDENTIAL CARE HOMESFACILITY NUMBER:
198600930
ADMINISTRATOR:JOCELYN MANALOFACILITY TYPE:
735
ADDRESS:414 S ABELIAN AVETELEPHONE:
(626) 913-4707
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY:4CENSUS: 2DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Jocelyn ManaloTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff speaks inappropriately to residents
Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Administrator Jocelyn Manalo.

Initial visit conducted 7/29/21 and consisted of the following: At 10:40 am, a physical plant inspection. Interviews were conducted with Clients #1-#3 (C1-C3) and staff #1 (S1) between 11am-12pm. Client (C1's) documents were requested: Identification and Emergency Information (Face Sheet), Physician Report, IPP, caregiver notes, LIC 500 Personnel Report, client roster. Staff #2 (S2)documents were also requested. S2 was not in the facility or available over the phone for interview.

On todays visit, S2 was still unavailable for interview and LPA Villalobos interviewed Staff #3 (S3) and delivered findings.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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-20210720163547
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: VICTORIA RESIDENTIAL CARE HOMES
FACILITY NUMBER: 198600930
VISIT DATE: 07/21/2022
NARRATIVE
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The investigation revealed the following: In regards to the allegation "Staff speaks inappropriately to residents" it was alleged that on 7/20/21 S2 told C1 to shut up before C1 left to the day program. (2) of (2) staff interviewed denied the allegation. (3) of (3) clients interviewed could not corroborate the allegation. Interviews conducted do not show that incident occurred. Interview with C1 was inconsistent. No further information was provided to LPA. Based on LPA's interviews and observations, 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.

In regards to the allegation "Staff hit resident" it was alleged that on 7/20/21 S2 hit C1 in the forehead before C1 left to the day program. (2) of (2) staff interviewed denied the allegation. (3) of (3) clients interviewed could not corroborate the allegation. Interviews show that S2 checks every clients temperature in the mornings before they go to their day programs. In order to check temperature, the facility has a thermostat that needs to be placed on the forehead to read temperatures. LPA reviewed a document dated 7/22/21 from Clients placement agency that does not show the allegation happened and the forehead hit was a temperature check. Based on LPA's interviews and filed reviewed, 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 and copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2