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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601749
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:00:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/11/2024 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241011103208
FACILITY NAME:SVS CITY OF INDUSTRYFACILITY NUMBER:
198601749
ADMINISTRATOR:ROZALIND FORDFACILITY TYPE:
775
ADDRESS:18725 E. GALE AVE.TELEPHONE:
(626) 626-4630
CITY:CITY OF INDUSTRYSTATE: CAZIP CODE:
91748
CAPACITY:60CENSUS: 60DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Karina De La Rosa, Program DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff had an inappropriate interaction with client.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Daniel Konishi and Luis DeLeon 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: LPAs obtained copies of the client and staff rosters, and interviewed Program Director, Staff #1 (S1) to Staff #4 (S4), Client #1 (C1) to Client #6 (C6) and Witness #1 (W1). LPAs reviewed C1’s personnel file, IPP, SVS media release, SVS consent for use of
photographs and video images, C1’s, SVS service notes.

The investigation revealed of the following: Allegation: "Staff had an inappropriate interaction with client." It's alleged that C1 was recorded by S1 against the facility policies.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
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 2
Control Number 28-AS-20241011103208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SVS CITY OF INDUSTRY
FACILITY NUMBER: 198601749
VISIT DATE: 10/18/2024
NARRATIVE
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The Program Director, and S1 to S4 denied the allegation. S1 stated that C1 told S1 about C1’s close relative’s legal matters. C1 was not engaging and sad about this situation regarding C1’s close relative so S1 reported to S2. After S2 received a call from C1’s responsible party. Allegedly, C1 claimed that this interaction between S1 and C1 was recorded which goes against the policy in the facility’s Program Design. On 9/24/2024, C1 was interviewed by the San Gabriel Pomona Regional Center where C1 recanted and said that S1 did not record the interaction with C1. When LPAs interviewed S1 over the telephone, C1 recanted the incident again and stated that no one recorded the interaction. Interview with W1 also indicated that C1 has a history of fabrication.

Based on the interviews conducted with clients and staff and documents reviewed, Although 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 allegation is UNSUBSTANTIATED.

Exit interview held and a copy of the report was provided to the program director Karina De La Rosa.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2