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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601822
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:47:05 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
10/11/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221011141816
FACILITY NAME:SPECIALIZED RESIDENTIAL MONTELLANOFACILITY NUMBER:
198601822
ADMINISTRATOR:CUA-KIM, JANEFACILITY TYPE:
735
ADDRESS:2767 MONTELLANO AVETELEPHONE:
(626) 961-2824
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:4CENSUS: 3DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Angela Williams (Administrator)TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff restraining residents in care.
Staff do not report unusual incidents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Angela Williams (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Client rosters, interviewed Staff #1, #2, #3, #4 in the den and attempted to interview Client #1 in the bedroom.

In regards to the allegation: Staff restraining residents in care. Interviews with Staff #1 to #4 indicate restraining techniques use to de-escalate a Client's aggressive behavior is a part of the CPI (Crisis Prevention Intervention) training. All Staff has certified CPI training and from the interviews conducted with Staff, there were 2 recalled incidents of restraint used within the past few months. There are no indications of multiple restraints used on a monthly basis per allegation details.

Continue to LIC9099C.......
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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-20221011141816
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: 10/20/2022
NARRATIVE
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In regards to the allegation: Staff do not report unusual incidents. Interviews with Staff #1 to #4 indicate the Administrator is notified after an incident of restraint is used on a Client which is also report to the department. LPA verified that 2 incident reports of restraint was received by the department.

Based on LPA's interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Angela Williams and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2