198601942-8-5-2024-28-AS-RORN-D7WVDK-20240807162053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601942
Report Date: 07/09/2024
Date Signed: 08/05/2024 02:59:27 PM

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
01/10/2024 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240110094010

FACILITY NAME:	INCLUSION SPECIALIZED PROGRAMS LLC - AGRA		FACILITY NUMBER:	198601942
ADMINISTRATOR:	KELLY HITCHENS		FACILITY TYPE:	735
ADDRESS:	5528 AGRA ST		TELEPHONE:	(562) 447-0991
CITY:	BELL GARDENS	STATE: CA	ZIP CODE:	90201
CAPACITY:	4	CENSUS: 4	DATE:	07/09/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Staff Veronica Mendez		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident sustained unexplained injuries/bruising while in care.

INVESTIGATION FINDINGS:

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The purpose of this report today 08/05/2024 is to remove confidential information and to add additional information to the 9099 that was delivered on 07/09/2024 with Unsubstantiated findings. LPA to obtain signatures and the finding will stay Unsubstantiated.
Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation. The investigation regarding the above mentioned allegation was conducted by Investigator / John Canto from the Investigation's Branch (IB). Upon arriving at the facility, LPA met with Staff / Veronica Mendez and was later joined by the Administrator Raymundo Lopez.
Prior visit was conducted at this facility on 01/11/2024 in reference to the allegation listed above and the following was done:
LPA along with Administrator Raymundo Lopez conducted a tour of the facility at 9:45 AM which included living room, dining room, kitchen, laundry area, 2 bathrooms, 4 client bedrooms (one is currently vacant), detached garage, front yard and back yard.
LPA checked the food supply which included a sufficient supply of 2 day perishables and 7 day non perishables.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240110094010

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: INCLUSION SPECIALIZED PROGRAMS LLC - AGRA	FACILITY NUMBER: 198601942
	VISIT DATE: 07/09/2024

NARRATIVE

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An investigation was conducted by the Investigations Branch (IB) Investigator John Canto from the
Department of Social Services and completed 05/23/2024 and included the following:
File Review for Client C1 which included obtaining and reviewing documents from the facility which included Special Incident Report's (SIR's), Client Development Evaluation Report (CDER), Admission Agreement, Personnel Schedules, Personnel Contact Information,.
Interviews were conducted with facility staff members, and facility clients.
Medical records from Keck Hospital of USC, and City of Bell Police Calls for Service Documentation were obtained.
Photographs were taken by the IB investigator during the course of the investigation as supportive evidence.
In regards to the allegation Resident sustained unexplained injuries/bruising while in care, based on interviews conducted and information gathered medical records were reviewed and Client C1 sustained a face-forward fall which caused bruising to the face.
Client C1 has the ability to self transfer from wheelchair to bed and vice versa with assistance.
Client C1 was at baseline the morning she sustained her fall.
Facility staff were 15 feet away from Client C1 as she suddenly stood up and fell forward.
Facility staff denied neglect.
Based on information gathered, there is no indication of staff neglecting the needs of clients at the facility.

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

An exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC9099 (FAS) - (06/04)

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