198601822-12-1-2021-28-AS-CYEE-C9Y6EU-20211222194518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601822
Report Date: 12/01/2021
Date Signed: 12/01/2021 09:22:35 AM

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
11/01/2021 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211101115524

FACILITY NAME:	SPECIALIZED RESIDENTIAL MONTELLANO		FACILITY NUMBER:	198601822
ADMINISTRATOR:	CUA-KIM, JANE		FACILITY TYPE:	735
ADDRESS:	2767 MONTELLANO AVE		TELEPHONE:	(626) 961-2824
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY:	4	CENSUS: 3	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Angela Williams-Interim Administrator		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff is not providing a comfortable environment for residents
Staff isolates the residents
Staff forced residents to do an activity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced subsequent complaint visit and delivered the findings today. LPA met with DSP-Donovan Covington and explained the reason of the visit. Shortly after, the interim administrator Angela Williams arrived.

The investigation consisted of the following: On 11/1/2021, LPA conducted the initial 10 days complaint investigation and interviewed four (4) clients (C1-C4), two (2) staff (S1-S2), interim administrator and district manager, reviewed clients' files and observed the food supply in the kitchen. LPA also obtained copy of clients Individual Personalized Plan (IPP). LPA also interviewed additional five (5) staff via phone.

The investigation revealed of the following: Allegation#1 “Staff is not providing a comfortable environment for residents” LPA interviewed four clients and two reported they feel comfortable to live in the facility and staff are nice to them. Clients have no concerns about the facility.
(See LIC9099C for Continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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 28-AS-20211101115524

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: SPECIALIZED RESIDENTIAL MONTELLANO	FACILITY NUMBER: 198601822
	VISIT DATE: 12/01/2021

NARRATIVE

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Allegation#2 “Staff isolates the residents.” LPA interviewed four clients and three clients stated that staff never isolated them. They can go in and out from their room freely. They are not afraid of any of the staff in the facility. LPA interviewed staff and they all denied the allegation and reported all clients were able to walk around the facility without any restriction and no client was scared of any staff and chose to stay in their room only.

Allegation#3 “Staff forced residents to do an activity.” LPA interviewed four clients and two stated there’s no staff ever forced them to an activity. They reported the staff are very polite to ask them and they do not mind doing the activity as it is good for their health. LPA interviewed the staff and they denied the allegation and reported the administrator implemented different activity for the clients and they never forced them to do the activity, only encourage them to do it.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Interim Administrator, Angela Williams. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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
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
11/01/2021 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211101115524

FACILITY NAME:	SPECIALIZED RESIDENTIAL MONTELLANO		FACILITY NUMBER:	198601822
ADMINISTRATOR:	CUA-KIM, JANE		FACILITY TYPE:	735
ADDRESS:	2767 MONTELLANO AVE		TELEPHONE:	(626) 961-2824
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY:	4	CENSUS: 3	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Angela Williams-Interim Administrator		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

1
2
3
4
5
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7
8
9

Staff are not providing adequate food service to residents

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) conducted an unannounced subsequent complaint visit and delivered the finding today. LPA met with DSP-Donovan Covington and explained the reason of the visit. Shortly after, the interim administrator Angela Williams arrived.

The investigation consisted of the following: On 11/1/2021, LPA conducted the initial 10 days complaint investigation and interviewed four (4) clients, two (2) staff, interim administrator and district manager, reviewed clients' files and observed the food supply in the kitchen. LPA also obtained copy of clients Individual Personalized Plan (IPP). LPA also interviewed additional five (5) staff via phone.

The investigation revealed of the following: Allegation “Staff are not providing adequate food service to residents. “LPA interviewed four clients and two clients reported they only got small portion of food and they cannot get any second plate for each meal as the facility was implemented the portion control for clients. (See LIC 9099C for continuation).

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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 28-AS-20211101115524

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: SPECIALIZED RESIDENTIAL MONTELLANO	FACILITY NUMBER: 198601822
	VISIT DATE: 12/01/2021

NARRATIVE

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LPA interviewed staff and reported that client had been complained and upset that they got small portion and they do not allow to get second plate. The staff reported that due to client's health condition, they tried to control client’s calorie and carbohydrate intake. LPA reviewed clients' documents and there’s no report indicate that clients need to be on any diet or small portion.

Based on the interviews conducted with staff and clients and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED California Code of Regulations, Title 22, Division 6 and Chapter 1 is being cited on the attached LIC 9099D.

Exit Interview conducted with the interim Administrator, Angela Williams. A copy of the report and appeal right was provided.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20211101115524

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: SPECIALIZED RESIDENTIAL MONTELLANO	FACILITY NUMBER: 198601822
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/15/2021 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	80072 Personal Right (a) Except for children’s residential facilities, each client shall have personal rights (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. The requirement is not met as evidenced by	1 2 3 4 5 6 7	The administrator will ensure the client shall have right to be comfortable accommodation to meet thier needs. The administrtor will retrain the staff for personal right and food service and send the copy of the training log to LPA by POC due date
	8 9 10 11 12 13 14	Interview with clients, staff and record review, it was reported client gets small portion of food and they cannot get second for the meal and they are not happy about it which posed the potenial risk to clients in care.	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: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5