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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601301
Report Date: 10/17/2024
Date Signed: 10/19/2024 07:53:24 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/10/2024 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241010085356
FACILITY NAME:AIM HIGHER COVINAFACILITY NUMBER:
198601301
ADMINISTRATOR:GUADALUPE RODRIGUEZFACILITY TYPE:
775
ADDRESS:440 SOUTH CITRUS AVETELEPHONE:
(626) 339-0400
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY:80CENSUS: 56DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Amiel Salgado, Program DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility failed to follow plan of operation for medical emergency.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted an initial 10 days complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Program Director Amiel Salgado allowed entry into the facility and also assisted with the visit.
The investigation consisted of the following: On today's date, LPA interviewed the program director, assistant director, Staff #1 (S1) to Staff #5 (S5) and Client#1 (C1) to Client#6 (C6) in the facility and Witness #1 (W1). LPA also obtained the client's roster, staff roster, updated Program Design, and special incident report.

The investigation revealed of the following: Allegation: "Facility failed to follow plan of operation for medical emergency." It's alleged that on 09/27/2024 at 11:16am on an outing to a local fast food restaurant, a vehicle while parking ran into a pole that landed on C1’s right arm that caused a minor bruise on C1’s right arm and that the facility staff failed to follow Emergency Medical procedures.


Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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 5
Control Number 28-AS-20241010085356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AIM HIGHER COVINA
FACILITY NUMBER: 198601301
VISIT DATE: 10/17/2024
NARRATIVE
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The Program Director, Assistant Program Director, S1 to S5 denied the allegation. The Assistant Program Director, S1 and S2 that were present at the time of the incident indicated that proper Emergency Medical procedures per Program Design was conducted. The facility staff attempted to obtain the driver's details which the driver refused. At 11:35am, the Assistant Program Director contacted C1’s responsible party. At 11:35am, C1 was also immediately taken back to Day Program facility and an ice pack was placed on her right triceps to relieve swelling. At 12:00pm, C1’s responsible party arrived to the Day Program facility. At 12:40pm, C1’s responsible party took C1 to the ER at the local hospital to treat the injuries. At 1pm, the Assistant Program Director attempted to contact the local police. At 1:50pm, Assistant Program Director was able to speak with the local police to report the incident and receive a case number. Per Program Design dated November 2013, based on the incident and type of injury, this is not listed as one of the Medical Emergencies that would require the facility to contact 911.

Based on the interviews conducted with clients and staff and documents reviewed, Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held and a copy of the report was provided to the program director Amiel Salgado.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/10/2024 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241010085356

FACILITY NAME:AIM HIGHER COVINAFACILITY NUMBER:
198601301
ADMINISTRATOR:GUADALUPE RODRIGUEZFACILITY TYPE:
775
ADDRESS:440 SOUTH CITRUS AVETELEPHONE:
(626) 339-0400
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY:80CENSUS: 56DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Amiel Salgado, Program DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not provide accurate incident report to appropriate parties.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted an initial 10 days complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Program Director Amiel Salgado allowed entry into the facility and also assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed the program director, assistant director, Staff #1 (S1) to Staff #5 (S5) and Client#1 (C1) to Client#6 (C6) in the facility and Witness #1 (W1). LPA also obtained the client's roster, staff roster, updated Program Design, and special incident report.

The investigation revealed of the following: Allegation: " Staff did not provide accurate incident report to appropriate parties." It's alleged that the facility did not provide sufficient details in the Special Incident Report sent to the appropriate parties on 09/28/2024.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20241010085356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AIM HIGHER COVINA
FACILITY NUMBER: 198601301
VISIT DATE: 10/17/2024
NARRATIVE
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The Program Director stated that on 09/27/2024, a Special Incident Report had minimized details of the incident and injury since the form had limited space for inputting the describing the incident which sent to the appropriate parties but did not send that Special Incident Report to Licensing. On 09/30/2024, the Program Director sent a revised Special Incident Report with sufficient details attached to the appropriate parties but did not send that Special Incident Report to Licensing. However, Licensing did not receive either Special Incident Report as required. It was confirmed by the Program Director that neither of the Incident Reports were not sent to Licensing.

Based on LPAs observations and interviews which were conducted, record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 3 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and Appeal Rights were provided to the Program Director Amiel Salgado.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20241010085356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AIM HIGHER COVINA
FACILITY NUMBER: 198601301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
82061(a)(1)(D)
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(a) Upon the occurrence, during the hours the day program is providing services to the client, of any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written
report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following
the occurrence of the event. (1) Events reported shall include, but not be limited to, the following: (D) Any unusual incident which threatens the physical or emotional health or safety of any client;

This requirement is not met as evidenced by:
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Facility will ensure that Special Incident Reports and Reportable Incidents are sent to Licensing as required. Program Director will send both Special Incident Reports to Licensing by the POC due date.
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Based on interview and record review, the facility did not send both Special Incident Reports to Licensing which poses a potential health, safety or 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5