198601499-6-13-2022-28-AS-MVAO-CH72VN-20220810174412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601499
Report Date: 06/13/2022
Date Signed: 06/13/2022 04:05:22 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
10/06/2021 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211006103328

FACILITY NAME:	SIERRA VISTA		FACILITY NUMBER:	198601499
ADMINISTRATOR:	KIMBERLY ISAAC		FACILITY TYPE:	735
ADDRESS:	670 W. HOWARD STREET		TELEPHONE:	(626) 398-1530
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	6	CENSUS: 4	DATE:	06/13/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Staff / Latrina Brown Assistant Administrator / Nancy Parker		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained bruises while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Resident sustained unexplained bruises while in care." Upon arriving at the facility, LPA met with Staff / Latrina Brown and was later joined by the Assistant Administrator / Nancy Parker who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 6/6/22 and 10/12/21, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Assistant Administrator, Staff members 1 - 4 (S1 - S4), Clients 2 - 4 (C2 - C4) and Quality Assurance Representative from Frank D Lanterman Regional Center (FDLRC). LPA was unable to interview C1 as C1 no longer resides at this facility. LPA attempted to interview Client 5 (C5) but was unsuccessful due to C5's cognitive impairment. LPA attempted to interview Staff 5 (S5) from Home Care Health (who happened to be C1's one to one staff for period June 2021 – September 30, 2021) but was unsuccessful as phone calls were not returned. (Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

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-20211006103328

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: SIERRA VISTA	FACILITY NUMBER: 198601499
	VISIT DATE: 06/13/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Also, copies of the following documents were obtained and reviewed in reference to C1;

• Client Face Sheet • Physician’s Report • Current Individual Program Plan • Appraisal/Needs and Services Plan • Facility notes for period 9/3/21 – 10/2/21 • Unusual Incident/Injury Reports

The investigation revealed the following;
Allegation: Resident sustained unexplained bruises while in care. The details of this allegation states that on 10/2/21 and 10/3/21, C1 went home to stay with her mother and the mother observed multiple bruises on C1. It was reported that C1 had a bruising on her lower buttocks area and also on her inner thigh.

Based on record reviews and interviews conducted, LPA learned that on the evening of 10/2/21, C1 was picked up by her father and spent the night at her father's house. On 10/3/21, C1's father took C1 to her mother's house and on 10/3/21, C1's mother discovered two bruises on C1. C1's father did not observe bruising while C1 spent the night at his place. Interviews conducted of staff confirmed no bruising was observed on the buttocks area or inner thigh of C1 prior to C1 going home for the weekend. Interviews conducted of clients, staff and Quality Assurance Representative from FDLRC confirmed no suspicion of abuse or malice towards C1 from staff. The Relationship between C1 and facility staff was described as "very loving". Based on interviews conducted and record reviews, LPA discovered that C1 had self injurious behaviors such as biting/slapping self, hitting others, falling on the floor and banging head on walls. C1 would also get physically aggressive with staff and other clients. The Pasadena Police Department was involved and came out and conducted interviews but no further action was taken. Frank D Lanterman Regional Center (FDLRC) conducted an investigation regarding the above mentioned allegation and the findings were Inconclusive. Based on record reviews and interviews conducted, there is insufficient evidence to support the allegation of "Resident sustained unexplained bruises while in care".

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 and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2