198601544-4-19-2024-11-AS-UCOL-D5VPN8-20240603112731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601544
Report Date: 04/19/2024
Date Signed: 04/19/2024 02:13:02 PM

Unsubstantiated

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
04/12/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240412134819

FACILITY NAME:	WEBSTER HOME		FACILITY NUMBER:	198601544
ADMINISTRATOR:	MUHAMMAD, SHIRENA		FACILITY TYPE:	735
ADDRESS:	2326 WEBSTER AVENUE		TELEPHONE:	(562) 490-9800
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90810
CAPACITY:	3	CENSUS: 3	DATE:	04/19/2024
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	VonEric Johnson, Administrator		TIME COMPLETED:	02:43 PM

ALLEGATION(S):

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Due to lack of supervision resident was physically assaulted

INVESTIGATION FINDINGS:

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On 04/19/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by VonEric Johnson, Administrator (S1) and the purpose of the visit was explained. S1 and LPA toured the facility.

The investigation consisted of the following:
On 04/19/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed three (3) out of ten (10) staff, one (1) witness and three (3) out of three (3) residents.

The investigation revealed the following:
Regarding the allegation: "Due to lack of supervision resident was physically assaulted.". It has been alleged that the perpetrator threw a bowl in the client’s direction but did not hit the client.

Report Continues, see LIC9099C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240412134819

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: WEBSTER HOME	FACILITY NUMBER: 198601544
	VISIT DATE: 04/19/2024

NARRATIVE

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Between 09:00AM and 12:50PM, on 04/19/24, LPA interviewed all three staff (S1-S3) who were involved in the allegation, and one client (C2). All four (4) interviewees were present during the allegation which occurred during the morning of 04/11/24. Between 1:20PM and 2:00PM, LPA interviewed client 2 (C1) and one witness (W1), both who were familiar with the date of the allegation. 1 client and 1 witness both disagreed with the allegation.
Interviews revealed that 3 out of 3 staff, 1 witness and 3 out of 3 clients have denied the allegation.

Record reviews revealed that C2's behavior summary includes property destruction and physical aggression.

Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
An exit interview was conducted with VonEric Johnson, Administrator (S1), and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC9099 (FAS) - (06/04)

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