198601749-5-16-2023-28-AS-RORN-CRWUGN-20230517153433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601749
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:43:45 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/27/2021 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210527081732

FACILITY NAME:	SVS CITY OF INDUSTRY		FACILITY NUMBER:	198601749
ADMINISTRATOR:	ROZALIND FORD		FACILITY TYPE:	775
ADDRESS:	18725 E. GALE AVE.		TELEPHONE:	(626) 626-4630
CITY:	CITY OF INDUSTRY	STATE: CA	ZIP CODE:	91748
CAPACITY:	60	CENSUS: 85	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Karina De La Rosa - Program Director		TIME COMPLETED:	11:58 AM

ALLEGATION(S):

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Facility is not allowing client to participate in program services due to vaccination status.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegation. LPA met with Karina De La Rosa (Program Director) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora obtained copies of the client and staff rosters, and interviewed Program Director, Staff 1 (S1), and attempted to interview Regional Center Representative. LPA obtained a copy of the facility's re-engagement plan, mitigation plan and a copy of regional center email approving the re-engagement plan.

The investigation revealed the following: regarding the allegation "facility is not allowing client to participate in program services due to vaccination status.”, it is alleged that the facility denied in-person services to a unvaccinated client.
(Continued to LIC 9099-C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 28-AS-20210527081732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SVS CITY OF INDUSTRY	FACILITY NUMBER: 198601749
	VISIT DATE: 05/16/2023

NARRATIVE

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Interview with Program Director revealed that this facility closed in March 2020 due to Covid-19 and reopened on 05/24/2021, but prior to reopening they had to create a re-engagement plan and submit to regional center. The regional center approved the re-engagement plan on 12/03/2020 and it was to be effective 04/30/2021. The re-engagement plan states the following: "the first participants to return to in person services will be those who have had their Covid-19 vaccines and can wear a mask in accordance with CDC guidelines." The facility provided remote services to the clients that were not vaccinated. However, a client's family member was unhappy with this facility's policy and the facility communicated with regional center. It was determined that vaccine status cannot be consider as a criteria for re-engagement. Therefore, the facility offered in-person services to all clients regardless of vaccination status starting 06/01/2021. It is important to note that PIN 21-21-ASC dated 04/15/2021 was released and addressed to all Adult Day Program Licensees, and it states the following: "No client/participant who refuses to be vaccinated against Covid-19 may be denied participation in any activity or service available to any other client/participant solely based on the decision to not receive the vaccine."

Based on LPA's interviews and documents reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 3 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210527081732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SVS CITY OF INDUSTRY	FACILITY NUMBER: 198601749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/23/2023 Section Cited CCR 82072(a)(3)	1 2 3 4 5 6 7	Personal Rights (a) Each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment...other actions of a punitive nature...including but not limited to: interference with the daily living functions...	1 2 3 4 5 6 7	Facility is to ensure that Title 22 Section 82072 regulations are met at all times. Additionally, facility will conduct an in-service training with all staff regarding this regulation and submit a sign in sheet with all staff signatures to CCLD by 05/23/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility did not allowed unvaccinated clients to attend Adult Day Program back in April 2021.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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