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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601844
Report Date: 04/12/2022
Date Signed: 04/13/2022 11:50:56 AM

Substantiated


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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20220405113559
FACILITY NAME:PEPPERWOOD AVENUE FACILITYFACILITY NUMBER:
198601844
ADMINISTRATOR:HAMPTON, SHELEANIA "CHINA"FACILITY TYPE:
735
ADDRESS:4735 PEPPERWOOD AVETELEPHONE:
(562) 982-4237
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:3CENSUS: 3DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Jasmine ContrerasTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff member yelled at resident in care.
INVESTIGATION FINDINGS:
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On 04/12/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced visit regarding the allegation above. LPA was met by Direct Support Staff and the purpose of the visit was explained.

Investigation Consisted of: Staff interviews (Administrative, Program Manager, Direct Support) Resident Interviews, Record Review, and Requested Documents (Staff Roster, Resident Roster, IPP, Internal Investigations Report, Letter of Resignation, Written Warnings)


Continued on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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 5
Control Number 11-AS-20220405113559
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
VISIT DATE: 04/12/2022
NARRATIVE
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Regarding Allegation: Staff member yelled at resident in care.

Interviews with Staff 2,3 generally stated that Staff 1 has an aggressive tone. Staff 2 stated that while they were in the rest room, they heard a commotion between Staff 1 (S1) and Resident 1 (R1). Staff 2 came out from the Rest Room, both R1 and S1 were standing in the dinning area. Staff 2 stated that they disengaged R1, and R1 listened. Resident 2 stated that S1 and R1 were going to “Square Up”, because R1 was being disrespectful to S1. Record Review revealed that R1 has had a previous verbal warning documented 02/01/22, for being overheard, calling a client a derogatory term, loud enough in the home that it could be perceived as verbal abuse. The home also conducted their own internal investigation, which documents statements from Resident 1, confirming that Staff 1 did in fact yell at R1.

“Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, (Title 22, Division 6, Chapter # 1), are being cited on the attached LIC 9099 D.”)

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20220405113559
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited
CCR
80072
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80072(a)(1)Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. This standard was not met as evidenced By: Interviews revealed Staff1 yelled at client in care


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Administrator will submit in service training for all staff regarding treating clients with dignity and respect by POC due date. Administration my submit proof via email of names of clients attended and subject to Jade.Jordan@dss.ca.gov
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20220405113559

FACILITY NAME:PEPPERWOOD AVENUE FACILITYFACILITY NUMBER:
198601844
ADMINISTRATOR:HAMPTON, SHELEANIA "CHINA"FACILITY TYPE:
735
ADDRESS:4735 PEPPERWOOD AVETELEPHONE:
(562) 982-4237
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:3CENSUS: 3DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Jasmine ContrerasTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff member inappropriately handled resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/12/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced visit regarding the allegation above. LPA was met by Direct Support Staff and the purpose of the visit was explained.

Investigation Consisted of: Staff interviews (Administrative, Program Manager, Direct Support) Resident Interviews, Record Review, and Requested Documents (Staff Roster, Resident Roster, IPP, Internal Investigations Report, Letter of Resignation, Written Warnings)



Continued on 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20220405113559
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
VISIT DATE: 04/12/2022
NARRATIVE
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Regarding Allegation: Staff member inappropriately handled resident in care.

Interviews with Staff 2 revealed they were in the restroom and did not witness any headphones attempted to be snatched off of R1. Staff 2 stated that R1 was asked to take them off prior, so that they could hear the staff questions, and take place in communicating with other residents at the dining table.

Interviews with Administration, staff 2, and 3 revealed that they have not witnessed Staff1 being physically aggressive towards any resident in care. LPA attempted to interview R1, regarding the allegation, but they declined to speak regarding the matter, Stating “ I didn’t do nothing, and I don’t want to talk about it.”

Interviews conducted with R2 stated “they could not remember if staff acted inappropriately by taking off R1’s headphones.” Record Review of Staff 1 written warnings did not reflect any write ups for inappropriately handling a resident in care.

Therefore; based on Interviews, observation and record review the Department Finds that : “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5