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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601937
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:24:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2024 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240905165257
FACILITY NAME:BRIGHTER OUTLOOK IFACILITY NUMBER:
198601937
ADMINISTRATOR:WENDY DE LEONFACILITY TYPE:
775
ADDRESS:2110 E. GLADWICK STREETTELEPHONE:
(310) 631-2070
CITY:RANCHO DOMINGUEZSTATE: CAZIP CODE:
90220
CAPACITY:90CENSUS: 55DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Wendy De LeonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee does not maintain staffing ratios as required.
INVESTIGATION FINDINGS:
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On 09/11/24, at 09:26am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-Day unannounced visit to the facility and was greeted by Wendy De Leon, Administrator. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings.

The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S6) and clients (C1-C3). Client Roster (Dated: August 2024), Staff Roster (Dated: September 2024), and Level One Distribution Sheet with Staff-Client Ratio (Dated: 07/02/2024-09/11/2024) were obtained from the facility.

The investigation revealed the following: Allegation- Licensee does not maintain staffing ratios as required.


Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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 11-AS-20240905165257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRIGHTER OUTLOOK I
FACILITY NUMBER: 198601937
VISIT DATE: 09/11/2024
NARRATIVE
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The details of the complaint alleged that the day program has been short staffed for the last few weeks and each staff is being assigned anywhere from five to seven clients each day, which is over the required staff to client ratio. On 09/11/24, from 9:26am-2:00pm, LPA interviewed staff (S1-S6) and clients (C1-C3) regarding the allegation. 6 of 6 staff (S1-S6) corroborated the allegation that the Licensee does not maintain staffing ratios as required. 6 of 6 staff (S1-S6) interviewed stated that there has been a lot of attendance problems in the facility with some staff out of the country, some on leave, and other staff that have quit. S1 stated that when they are short staffed, they try and pull staff from Brighter Outlook II if they have less clients on any given day to help with the staffing issue. LPA reviewed the Level One Distribution Sheet with Staff-Client Ratio (Dated: 07/02/2024-09/11/2024) and found that on average the staff-client ratio was one staff to six clients on any given day; while the plan of operations specifies that Brighter Outlook is a Regional Center funded program and the staff-client ratio is supposed to be one staff to three clients. LPA observed on 9/11/24 that the census for the clients was 55 and staff 11. The ratio of staff-client was 1:5.

LPA interviewed clients C1-C3 about the allegation and 2 of 3 clients that were interviewed corroborated the allegation that Licensee does not maintain staffing ratios as required. Clients stated that they feel the day program needs more staff to meet the needs of all the clients enrolled in the program.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation: Licensee does not maintain staffing ratios as required, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (3) are being cited on the attached LIC 9099D.

Note: *Citations not cleared by the due date will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.

Deficiencies are issued and plans of corrections were discussed.



An exit interview was conducted with Wendy De Leon, Administrator, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240905165257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRIGHTER OUTLOOK I
FACILITY NUMBER: 198601937
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
CCR
82022(a)
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82022(a) Plan of Operation. Each licensee of an adult day program shall have and maintain on file a current, written, definitive plan of operation. This requirement is not met as evidenced by:
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Administrator will ensure staffing ratio to clients is maintained according to their plan of operation. Administrator will develop a written plan on how they will meet facilities staffing ratios as required by regional center and submit it in writing to LPA Perry Scott by POC due date of 09/25/2024 to perry.scott@dss.ca.gov .
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Based on interviews and records reviewed the administrator did not adhere to the Plan of Operations. This facility is a Regional Center funded program and violated their Plan of Operation in that the facilities staff-client ratio is one staff member to three clients. Timesheet indicates that from 7/2/24-9/11/24 the average ratio was one staff member to six clients. Which poses a potential Health & Safety risk to clients in care.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
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