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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601495
Report Date: 01/12/2024
Date Signed: 04/03/2024 11:45:08 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20231211134811
FACILITY NAME:HOME 2 U 4FACILITY NUMBER:
198601495
ADMINISTRATOR:GWENDOLYN COLEFACILITY TYPE:
735
ADDRESS:9140 S. HOBART BLVDTELEPHONE:
(310) 702-9572
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:4CENSUS: 4DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
07:56 AM
MET WITH:Keith ColeTIME COMPLETED:
07:57 AM
ALLEGATION(S):
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Staff did not provide adequate supervision, resulting in resident getting assaulted by another resident.

INVESTIGATION FINDINGS:
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The original LIC9099 and LIC9099C dated 01/12/2024, are being amended. The amendment does not change the findings of this investigation. On 01/12/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to render findings of the investigation. LPA Richard met with staff Stacey and spoke to licensee Keith Cole via telephone and the purpose of today's visit was explained. LPA and staff toured the facility.
The investigation consisted of the following: On 12/13/2023, Licensing Program Analyst (LPA) Antonine Richard initiated the complaint investigation and conducted a tour of the physical plant. LPA Richard requests the following documents. Facility Personnel Report and Resident Roster, Staff's S1. Personnel Records which includes Personnel Record (LIC 501), Employee Training, and clients C1 and C2's Client Records which includes Pre-placement Appraisal Information (LIC 603), Admission Agreement, Individual Program Plan (IPP), Physicians Report (LIC 602). Identification and Emergency Information (LIC 601), Unusual Incident/Injury Reports (LIC 624), any record of changes in mental emotional and social functioning and Mental Health Assessments.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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 5
Control Number 11-AS-20231211134811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HOME 2 U 4
FACILITY NUMBER: 198601495
VISIT DATE: 01/12/2024
NARRATIVE
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The investigation revealed the following:

Regarding Allegation: Staff did not provide adequate supervision, resulting in resident getting assaulted by another resident. interviews revealed the following: Client C1 was physically punched in the face by Client C2 which caused injury to client C1's left eye. On 12/11/2023 Client C1 was taken to the hospital by the ambulance from the day program because C1 left eye was bleeding. C1 stated that while waiting in the living room at the facility C1 and C2 started arguing about C1 bag that was on the floor, the argument escalated, C2 punched C1 in the face. C2 admitted yes to punching C1 in the face. S1 and S2 both stated C2 punched C1 in the face while arguing. S1 failed to prevent the resident C2 from hitting C1. Staff interviews indicated that S1 was present and heard the residents argue and she heard the argument escalate and failed to act immediately, at least verbally to de-escalate the argument. Then C1 went to the day program. S1 stated that she didn't notice C1 was bleeding when C1 left. Witnesses at the day program, stated that C1 was bleeding and in pain since they know the client has a history of seizures, they decided to call the ambulance. When the ambulance arrived, they decided to take C1 to the hospital. LPA Richard also reviewed the facility noted created by the staff the day of the incident happened it is in fact C1 did get physically injured by C2 at the facility. Based on LPA observations and interviews which were conducted and the records that were reviewed. Based on records reviewed, interviews conducted facility staff failed to properly supervise C2 resulting in C2 punching C1 causing injuries to C1 left eye. The preponderance of evidence standard has been met; therefore, the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 & 6 are being cited on the attached LIC 9099-D.

Exit interview conducted, appeal rights explained and a copy of this report and appeal rights was provided to the Licensee Keith Cole.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20231211134811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HOME 2 U 4
FACILITY NUMBER: 198601495
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/22/2024
Section Cited
CCR
82165(a)(d)(3)
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82165(a)(d)(3) The licensee shall ensure staff who are participate in approve or providing care and supervision. The licensee shall provide care and supervision as necessary to meet the clients needs. Alternative methods of handeling aggressive and assaultive behavior.
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Licensee is to review Title 22 Regulation section 82165 (a)(d)(3) for how to train staff at the facility. Licensee will Submit a plan of correction to LPA via email
Antonine.Richard@dss.ca.gov. Phone(323)
516-4092
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The facility did not provide care and supervision to client C1, while in care, as a result client C2 punched client C1 caused injuries while in care.
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Type B
01/22/2024
Section Cited
CCR
85165(d)(1)(2)(3)
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85165(d)(1-3)Emergency Intervention Staff Training(d)The emergency intervention training:(1) Techniques of group and individual behavior...(2) Methods of de-escalating volatile. (3) Alternative methods of handling aggressive and assaultive behavior...


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Licensee is to review Title 22 Regulation section 85165 (d) (1) (2) (3) On how to train staff at the facility. Licensee will submit a POC to LPA via email. Antonine.richard@dss.ca.gov.
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The facility did not provide care and supervision to client C1, while in care, as a result client C2 punched client C2 punched C1 caused injuries while 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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20231211134811

FACILITY NAME:HOME 2 U 4FACILITY NUMBER:
198601495
ADMINISTRATOR:GWENDOLYN COLEFACILITY TYPE:
735
ADDRESS:9140 S. HOBART BLVDTELEPHONE:
(310) 702-9572
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:4CENSUS: 4DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
07:56 AM
MET WITH:Keith ColeTIME COMPLETED:
07:57 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff caused injuries to client in care.
Staff assaulted client in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/12/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to render findings of the investigation. LPA Richard met with staff stacey and spoke to licensee Keith Cole via telephone and the purpose of today visit was explained. LPA and staff toured the facility.

The investigation consisted of the following: On 12/13/2023, Licensing Program Analyst (LPA) Antonine Richard initiated the complaint investigation and conducted a tour of the physical plant. LPA Richard request the following documents. Facility Personnel Report and Resident Roster, Staff's S1. Personnel Records which includes Personnel Record (LIC 501), Employee Training, and clients C1 and C2's Client Records which includes Pre-placement Appraisal Information (LIC 603), Admission Agreement, Individual Program Plan (IPP), Physicians Report (LIC 602), Identification and Emergency Information (LIC 601), Unusual Incident/Injury Reports (LIC 624), any record of changes in mental emotional and social functioning and Mental Health Assessments.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20231211134811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HOME 2 U 4
FACILITY NUMBER: 198601495
VISIT DATE: 01/12/2024
NARRATIVE
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The investigation revealed the following:

Regarding Allegation #1: Staff caused injuries to client in care.

Regarding Allegation: #2 Staff assaulted client in care.

Records reviewed, observed, and interviewed, Client #1 (C1) was physically punched in the face and assaulted by Client #2 (C2) which caused injury to client 1(C1) left eye. LPA interviewed client #1 (C1) and client stated that the staff did not cause the injuries to the left eye, it was client 2 (C2) who punched C1 and caused the injuries. C2 admitted yes to punching C1 in the face. LPA interviewed the staff about the incident that day. Staff #1(S1) stated that she wouldn’t punch or hurt any clients while caring for them. Staff #1 stated she tried to separate clients (C1 and C2) from fighting, however when C2 punched C1 she intervened and made C2 leave the living room. Staff S1 stated that she tried to separate them by coming between them both.

Based on observations, interviews, and record reviews the 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 allegations: Staff caused injuries to client in care. and Staff assaulted client in care. Both allegations are Unsubstantiated. according to California Code Regulation Title 22 no deficiency issued.

An exit interview was conducted an a copy of the report was provided to Licensee Keith Cole.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5