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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601228
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:31:54 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
12/06/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211206110238
FACILITY NAME:VERMONT CARE CENTERFACILITY NUMBER:
198601228
ADMINISTRATOR:PHIDIAS BARRIOSFACILITY TYPE:
735
ADDRESS:1316 S. VERMONT AVE.TELEPHONE:
(213) 384-1682
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:76CENSUS: 55DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jeanine Machado, House Manager.
TIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
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5
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9
Resident was physically assaulted by another resident while in care.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Jose Villalobos conducted an announced initial complaint investigation for the allegations listed above. LPA met with Staff Jeanine and discussed the purpose for todays visit.

The investigation consisted of the following: LPA interviewed Staff #1-#5 (S1-S5) and Clients #1-#6 (C1-C6). LPA requested a copy of: staff roster, client roster, the following documents for client #1: Admission agreement, Emergency Identification page(ID Page), current Physicians report, Appraisal needs and services plan. LPA Villalobos also toured the physical plant.

In regards to the allegation "Resident was physically assaulted by another resident while in care." it was alleged that C1 was physically assaulted by another unknown client of the facility. (5) of (5) staff interviewed denied the allegation. (6) of (6) clients interviewed could not corroborate the allegation....

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: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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-20211206110238
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: VERMONT CARE CENTER
FACILITY NUMBER: 198601228
VISIT DATE: 12/13/2021
NARRATIVE
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Interviews show that staff do not have knowledge of the alleged incident occurring. LPA was not provided with a time of which the alleged incident had occurred. C1 stated to LPA that the alleged incident did not happen and C1 had never been assaulted in the facility. LPA did not observe documentation of C1 being assaulted in the facility. Based upon interviews conducted and observation, the findings indicate that, 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 Jeanine Machado and a hard copy of the report was provided.


NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2