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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601427
Report Date: 07/13/2023
Date Signed: 07/13/2023 08:20:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230622142400
FACILITY NAME:PEAK PERFORMANCE SPECIALIZED HOMEFACILITY NUMBER:
198601427
ADMINISTRATOR:VANESSA REEDFACILITY TYPE:
735
ADDRESS:4513 3RD AVETELEPHONE:
(323) 369-3987
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY:4CENSUS: 3DATE:
07/13/2023
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Daveante MannTIME COMPLETED:
04:19 PM
ALLEGATION(S):
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9
Staff do not distribute residents' medications as prescribed.
Staff do not provide residents with clean linens.
INVESTIGATION FINDINGS:
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On 07/13/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. LPA was greeted by House Manager Daveante Mann. LPA explained the purpose of the visit is to complete the investigate on the allegations mentioned in this complaint.

The investigation consisted of the following: Interviews with staff #1-#2 (S1-S2) clients #1-#3 (C1-C3) and witnesses #1-#3 (W1-W3), a review of (C1's) service records, and other pertinent documents associated with this complaint. A review of staff and resident rosters. A tour of the facility was conducted.

(Evaluation Report continues on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
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 3
Control Number 11-AS-20230622142400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEAK PERFORMANCE SPECIALIZED HOME
FACILITY NUMBER: 198601427
VISIT DATE: 07/13/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff do not distribute residents' medications as prescribed.

The details of the complaint alleged client #1(C1) is not receiving medications as prescribed. The complainant reported (C1) is supposed to have medications between 5:00 am – 6:00 am daily, however, the staff does not distribute (C1’s) medications until 6:00 am – 7:00 am. The complainant reported that (C1) wakes up at 2:00 am with a headache and is not given Excedrin for pain even when (C1’s) has doctor's approval to distribute it to (C1).

In an interview with client #1 (C1) stated that (C1) is new at this facility and formally lived with a family member in a private home. (C1) reported that (C1) managed the prescription medications. (C1) stated that no family member assisted with the distribution of medications including the pain reliever Excedrin at 2:00 am. When (C1) was admitted to this group home on 05/24/ 23, (C1) has not missed any of the prescribed medications, but (C1) no longer manages own medications as (C1) used to. (C1) is now assisted by staff and (C1’s) meds are distributed at 7 am, 2 pm, 5 pm, and 8 pm daily. According to the physician order for (C1), (C1) is prescribed nine (9) medications that did not include Excedrin dated 05/01/2023. A review of clients #1-#3(C1-C3) Medication Administration Records for May and June 2023 revealed to be accurate and maintained in order. There has been no medication missed by (C1), as verified in the (MAR). The South-Central Los Angeles Center (SCLAR) service coordinators witnesses #1 -#3 (W1-W3) had no issues or concerns with the care and supervision of their consumers. (W1) verified that (C1) is adjusting to living in a group home rather than a private residence and being independent without any set rules. (W1) said that (C1) was used to taking Excedrin even when it wasn't prescribed by (C1's) primary physician. The pain reliever Excedrin's common side effect can cause increase seizures in which (C1) is diagnosed with a seizure disorder. Interviews conducted with staff #1-#2 (S1-S2) verified that staff have completed Direct Support Professional (DSP) on how to assist individuals in the self-administration of medication training. (S1-S2) claimed they were unaware that (C1) had any issues with the distribution of medications. Interviews conducted with (C2-C3) who were present at the facility were unable to hold a conversation as a result of their disability. Based on the information gathered, there is no sufficient evidence to support the allegation mentioned above.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230622142400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEAK PERFORMANCE SPECIALIZED HOME
FACILITY NUMBER: 198601427
VISIT DATE: 07/13/2023
NARRATIVE
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Allegation: Staff do not provide residents with clean linens.

It is alleged that staff do not provide client #1 (C1) with clean linens. The complainant reported that (C1's) bed linens are not regularly changed and had not been replaced for two to three days.

The Department interviewed client #1 (C1) who expressed having no issues or concerns in this matter. (C1) stated that bedding sheets are regularly replaced at least twice a week. The Department inspected on 06/29/23 and 07/13/23 client’s #1-#3 (C1-C3) beds, bed linens, and comforters, were clean and presentable during the visit. An interview with staff #1 - #2 (S1-S2) verified that bed sheets are replaced twice a week or as needed. (C1) is not incontinent and would not require frequent changes of bed linens weekly. Interviews with (SCLAR) coordinators witnesses #1-#3 (W-W3) had no concerns or issues with the facility and felt the facility provided healthful and comfortable accommodations to their consumers. Interviews were conducted with (C2-C3) who were present at the facility and were unable to hold a conversation due to their disability. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Based on information gathered, an inspection of the facility, observation, and interviews conducted, documents reviewed, the Department found no evidence to support the allegations mentioned above.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.



An exit interview conducted with Daveante Mann and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3