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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601931
Report Date: 01/16/2024
Date Signed: 01/16/2024 01:46:46 PM

Substantiated


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
07/08/2022 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220708164620
FACILITY NAME:FLAGSHIP @ PAYSONFACILITY NUMBER:
198601931
ADMINISTRATOR:MAGEE, LORINGFACILITY TYPE:
735
ADDRESS:18445 PAYSON STTELEPHONE:
(626) 331-2396
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:4CENSUS: 4DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Administrator Loring MageeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff yelled at resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s Sanjay Vaid and Luis Mora conducted a subsequent complaint visit regarding the allegation stated above. LPA's met with Administrator Loring Magee and explained the reason for the visit.

The investigation consisted of the following:on 07/14/2022, LPA Nune Margaryan interviewed the Administrator, Staff members #1 - #3 (S1 - S3), Clients #1 - #3 (C1 - C3). Obtained copies of Staff & Clients rosters, reviewed C1's files and obtained copies of Face Sheet, Physician's Report, Assessment Behavior Intervention Plan, SIR dated on 7/11/22 and other relevant documents. During todays visit 01/16/2024, LPAs obtained copies of staff and client records, reviewed resident & staff files, interviewed Administrator, Staff 1 (S1), Client 1- Client 4 (C1-C4), regional center service coordinator, and attempted to interview Staff 2 - Staff 3 (S2 - S3). LPA obtained a copy of regional center investigation report and corrective action plan, and facility in-service trainings. (Continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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 3
Control Number 28-AS-20220708164620
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: FLAGSHIP @ PAYSON
FACILITY NUMBER: 198601931
VISIT DATE: 01/16/2024
NARRATIVE
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Regarding the allegation "staff yelled at resident" it is alleged that a staff yelled at client 1 (C1). Administrator stated that the allegation did occur and a corrective action plan was issued to the facility by regional center. Administrator conducted in-service training with the staff regarding this matter on 08/02/2022 and the two staff that yelled at the client were terminated. Administrator stated that zero tolerance is practiced at the facility and staff need to speak with clients at close proximity and attentively to understand their issues. Regional center service coordinator stated that an investigation regarding this allegation was conducted on 07/11/2022 by regional center and substantiated the allegation. LPAs reviewed the regional center's investigation report and it stated that there was 2 staff that yelled at C1. These two staff were terminated on 07/20/2022.

Based on LPAs interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 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: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220708164620
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: FLAGSHIP @ PAYSON
FACILITY NUMBER: 198601931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2024
Section Cited
CCR
80072(a)(1)
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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 requirement is not met as evidence by:
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Licensee will conducted an in-service training regarding Title 22 Section 80072 and submit a training log with staff signatures to CCLD by 01/23/2024.
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Based on interview and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Two staff yelled at Client 1 (C1).
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During the visit, it was determined that the licensee conducted in-service training regarding this matter on 08/02/2022.
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3