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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600948
Report Date: 07/12/2024
Date Signed: 07/12/2024 03:29:25 PM

Substantiated


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
07/24/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230724131734
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL FAIRVIEWFACILITY NUMBER:
198600948
ADMINISTRATOR:SERGIO CALDERONFACILITY TYPE:
735
ADDRESS:114 FAIRVIEW AVETELEPHONE:
(626) 576-0477
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:4CENSUS: 4DATE:
07/12/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Justin Johnson, Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff yelled at clients in care.
Facility failed to follow personal rights of clients in care.
Facility does not meet food guidelines.
Facility does not maintain emergency water supplies.
Facility does not keep sufficient incontinence supplies.
Facility does not keep accurate records of client funds and personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator Justin Johnson.

The investigation consisted of: On 7/26/23, LPA conducted a physical plant inspection with focus on food supply, garage storage areas, and incontinence supply inventory. Staff (S2-S4) were interviewed, but no residents were interviewed because they are non-verbal. Resident (R1- R4's) Face Sheet, Physician Report, Individual Program Plan (IPP), Resident Personal Property and Valuables, Client Personal Possessions Inventory, Resident Diet List, and Weekly Food Menu, and Personal and Incidental Funds Record ( P & I). Staff (S1's) file documents [Personnel Record, Disciplinary Action/Coaching Corrective Action Form, and incident report (5/29/23) were obtained. During today's visit, food and incontinence supply inventory was checked, and staff (S5- S8) were interviewed.

***Narrative continued on LIC9099C.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
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 6
Control Number 28-AS-20230724131734
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 FAIRVIEW
FACILITY NUMBER: 198600948
VISIT DATE: 07/12/2024
NARRATIVE
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Allegation: Facility staff yelled at clients in care. It is alleged that DSP staff (S1) yells and screams phrases "Come on get up", "Oh my ..., you shit again!" and "Agh yuck" when residents needed bowel and incontinence care. According to information obtained, on 5/29/2023 seven (7) staff members composed a and signed a letter notifying Administrator of verbal abuse and neglect. Administrator stated that staff (1) was placed on administrative leave pending internal and Regional Center investigation findings. Administrator said that they never observed staff (S1) verbally abusing residents, and became aware of the incidents when the letter was received. A total of 5 staff were interviewed, of which 3 confirmed the allegation, and the other 2 staff stated they never heard or witnessed verbal abuse. One (1) staff stated that staff (S1) raised their voice towards residents and reduced the tone of voice when speaking to staff. Regional Center findings supported the allegation. A Corrective Action Plan (CAP) was provided on 7/21/2023.

Allegation: Facility failed to follow personal rights of clients in care. It was reported that staff (S1) failed to provide bowel and incontinence care to residents in care as required. It is alleged that S1 did not like to change resident's incontinence diapers, and would ask other staff to do it. Staff interviews revealed that staff (S1) was not providing incontinence care as required and S1 targeted resident (R2) because the resident is non-ambulatory and non-verbal. Additionally, staff reported that it appeared that staff (S1) was not able to handle incontinence care of residents because one time S1 vomited and refused to change the resident. Administrator stated that based on their observations and knowledge staff were respecting the personal rights of residents. However, the Regional Center interviewed alleged perpetrator staff (S1) and they acknowledged that they did not take care of the resident's needs, and only assisted when asked by other staff. Staff interviews revealed that S1 preferred to stay in the kitchen and cook in order to avoid incontinence care responsibilities.

Allegation: Facility does not meet food guidelines. It was reported that based on observation the facility had insufficient fresh perishable food and was primarily serving residents frozen prepackaged food. Interviews revealed that staff typically served the residents cereal or yogurt for breakfast, and offered bologna, tuna, or deli cuts sandwiches for lunch, and dinner meals are cooked by staff. Staff reported that all 4 residents have modified diets that were being followed, and they thought that the residents were being given sufficient protein and vegetables in their sandwiches. Based on record review, the findings indicate that 2 residents are on chopped diet, 1 resident has a lactose free diet, and 1 resident requires a pureed diet. According to Regional Center observation and record review, the residents were not being served the registered dietician (RD's) food items listed on the menu, and the food items served did not meet their individual dietary needs.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20230724131734
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 FAIRVIEW
FACILITY NUMBER: 198600948
VISIT DATE: 07/12/2024
NARRATIVE
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Allegation: Facility does not maintain emergency water supplies. It is alleged that the facility had very little emergency supply stored in the garage and was not being replaced. Administrator stated that there was plenty of emergency water supply in storage all the time. All staff stated that there was sufficient water in the garage, as well as, a drinking barrel next to the sink. On 7/26/2023 and today, sufficient emergency water supply in the garage and inside the facility was observed. However, based on Regional Center observation, at the time of their visit, insufficient emergency water supply was observed. Administrator did not know the reason why there was not enough water supply when Regional Center visited the facility.

Allegation: Facility does not keep sufficient incontinence supplies. It was reported that the facility did not have sufficient incontinence adult diaper supplies to meet the care needs of residents. According to information obtained, incontinence supplies had not been delivered in months, and as a result facility staff were bringing limited supplies from other facilities. According to staff interviews, there were issues with resident's insurance payments for incontinence supplies and that is the reason the facility failed to keep sufficient quantities of incontinence adult diapers in the premises. During today's visit, sufficient incontinence supplies were observed in storage.

Allegation: Facility does not keep accurate records of client funds and personal belongings. According to information obtained resident (R3) purchased a designer fragrance that was not added to personal belongings inventory list, and was kept in a filing cabinet in the garage due to concerns with the possibility of staff stealing the fragrance. Upon review, of P & I records and inventory list it was discovered that documentation of items purchased was missing. Multiple transactions of clothing expenses were not documented. Per staff interviews, the Administrator and house lead were responsible for ensuring documentation is updated and accurate. Former Administrator stated that these forms were audited every 3-4 months. Administrator reported they did not have knowledge that the fragrance was in storage. During today's visit, P & I and inventory documents were audited and reviewed. No discrepancies were observed.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted with Alyssa Walker. Findings were explained and discussed with Administrator Justin Johnson. A copy of the report and appeal rights were issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20230724131734
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 FAIRVIEW
FACILITY NUMBER: 198600948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
80072(a)(3)
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Personal Rights. Except for children’s residential facilities, 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 .....
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Administrator agreed to submit a written plan of correction and proof of in-service trainings that have been conducted as a result of the investigation.
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Based on interviews conducted, the findings indicate that staff (S1) verbally abused residents in care by yelling and saying inappropriate remarks to the residents. On 11/7/2023, S1 was terminated; this posed an immedite health, safety, and personal rights risks to persons in care.
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Type B
07/26/2024
Section Cited
CCR
80077.4(b)(4)
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Care for Clients with Incontinence. If a licensee accepts or retains a client who has bowel and/or bladder incontinence, the licensee is responsible for all of the following: Ensuring that clients with incontinence are kept clean and dry, and that the facility remains free of odors.
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Administrator agreed to submit a plan of correction that states how the issue was addressed by the company. Submit a copy of staff duties check list, and any other supporting documents.
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Based on investigation findings, staff (S1) neglected incontinence care of residents. Staff (S1) acknowledged neglect; which posed a potential healh, safety, and personal rights risk to residents 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20230724131734
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 FAIRVIEW
FACILITY NUMBER: 198600948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
80076(a)(1)
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Food Services. In facilities providing meals to clients, the following shall apply: All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Administrator agreed to submit a written plan of correction that includes recommendations based on client needs and restrictions. Submit a copy of their current dietician approved food needs.
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Based on observation from CCL staff and Regional Center staff, the facility failed to have sufficient fresh perishable food
and was primarily serving residents frozen prepackaged foods that are not nutritious, which posed a potential health, safety, and personal rights risk to persons in care.
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Type B
07/26/2024
Section Cited
CCR
85076(d)(1)
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Food Service.The licensee shall meet the following food supply and storage requirements: Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met evidenced by:
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Administrator agreed to submit in writing how the deficiency of emergency water supply was corrected.
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Based on Regional Center observations in June 2023, the facility failed to have emergency water supply in storage, which poses a potential health, safety, and personal rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20230724131734
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 FAIRVIEW
FACILITY NUMBER: 198600948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
80077.4(b)(8)
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Care for Clients with Incontinence. If a licensee accepts or retains a client who has bowel and/or bladder incontinence, the licensee is responsible for all of the following: Providing needed incontinence supplies when the client or a third party is unable to do so. This requirement was not met evidenced by:
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Administrator agreed to submit a written plan of correction that addresses how the facility will obtain and maintain supplies on a regular basis by using medical insurance and suppliers.
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Based on observation, the facility failed to maintain sufficient supply of incontinence adult briefs for residents, and in June 2023 it was determined supplies had not been delivered for months; therefore staff were bringing limited supplies from other facilities, which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
07/26/2024
Section Cited
CCR
80070(b)(14)
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Client Records. Each record must contain information including, but not limited to, the following: An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.
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Administrator agrees to submit a written plan of correction that states which staff will have access to P & I monies, as well staff procedures for updating and maintaining resident's personal inventory lists.
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Based on record review and interviews conducted, facility staff failed to maintain accurate records in the personal property and valuables and P & I forms items purchased and correct money totals. Additionally, purchased cologne was found stored unopened in the garage, which poses a potential health, safety, and personal rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6