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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601943
Report Date: 02/22/2024
Date Signed: 02/22/2024 11:25:59 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
04/25/2023 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230425082059
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WILCOXFACILITY NUMBER:
198601943
ADMINISTRATOR:JUAN RAMIREZFACILITY TYPE:
735
ADDRESS:8134 WILCOX AVETELEPHONE:
(562) 447-0991
CITY:CUDAHYSTATE: CAZIP CODE:
90201
CAPACITY:3CENSUS: 3DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Raymundo LopezTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility staff did not adequately supervise resident.
Facility staff did not ensure that resident's medications are being appropriately managed.
Facility staff is not ensuring that resident's needs are being met.
INVESTIGATION FINDINGS:
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The purpose of this report is to include additional information and to change the findings to Substantiated from Unsubstantiated regarding allegation Resident threatens other residents and staff.
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent complaint visit and was greeted by Staff Veronica Mendez and explained the reason for the visit.
The purpose of the visit is a subsequent complaint visit to deliver the findings from the original complaint dated 04/25/2023.
At today's visit Client C 1's medication for today was reviewed along with the Medication Administration Record (MAR) and Medication Verification Log from 04/01/2023 to 04/30/2023.
The initial visit was conducted on 05/01/2023 and the following was done:
Interview was conducted with Administrator Raymundo Lopez at 9:50 AM.
Interviews were conducted with Staff S 1 and Staff S 2 from 10:05 AM to 11:05 A.M.
File for Client C 1 was reviewed and various documents were submitted.
A subsequent visit was conducted on 11/28/2023 and the following was done:

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: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 5
Control Number 28-AS-20230425082059
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 - WILCOX
FACILITY NUMBER: 198601943
VISIT DATE: 02/22/2024
NARRATIVE
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Interview was conducted with Staff Robert Diaz at 1:00 PM.
Interviews were conducted with Staff S 1 and Client's C1 and Client C 2 from !:15 PM to 2:15 PM.
In regards to the allegation Facility staff did not adequately supervise resident, based on interviews conducted and information gathered Client C 1 stated when she ran out staff will be right behind her to get her to go back. Also said that staff is good helping us out.
Client C 2 stated with behaviors staff will watch to make sure it doesn't get bad. They make sure the house is run right. Stated Client C 1 has behaviors and staff handle it well. Said she did run out and staff did a good job trying to get her back.
Staff stated that she is not supervised is not correct. She will close the gate, but she runs across the street, but staff follow right by her. She will attack cars. They have to back up because she gets physical and spits at staff. They are always there and not far behind. Staff redirect her and ask her what she is upset about.
Interview with Regional Center Representative on 02/20/2024 at 9:20 AM who stated that Client C1 does not require a 1:1 and facility is operating within required ratio and it should also be noted that the gate cannot be locked per Title 22
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.
In regards to the allegation Facility staff did not ensure that resident's medications are being appropriately managed., based on interviews conducted and information gathered Client C 1 stated that hey give her meds every day and they have never missed.
Client C 2 stated that they give meds every day and they have never missed.
Staff stated that medication has been administered per physician's orders for all client's and medication is verified within 1 hour of being administered on each shift in addition to MAR Log initialed and also document on back of MAR reasons if medication is missed.
At today's visit medication for Client C1 was administered per physician's orders and MAR Log initialed for today. MAR Log was also completed for 04/01/2023 to 04/30/2023 with any doses missed documented with the reason. Medication Verification Log was also completed for 04/01/2023 to 04/30/2023.
Based on the fact that the facility has sought assistance from C1's responsible parties and notified them of incidents, there is no evidence to support the allegation as facility has made reasonable efforts to seek assistance.
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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230425082059
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 - WILCOX
FACILITY NUMBER: 198601943
VISIT DATE: 02/22/2024
NARRATIVE
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In regards to the allegation Facility staff is not ensuring that resident's needs are being met., based on interviews conducted and information gathered Client C 1 stated that they give her meds every day and they have never missed. Said she does hygiene on her own but they help her to make her life easier
Client C 2 stated that staff assist with meds and Staff does take care of their needs,
Staff stated that they remind Client C 1 about hygiene and encourage her to shower.
She chooses breakfast and they let her pick. Staff assist with all meals.
Also will take her to park.
Staff stated they assist all the client's with all their ADL's on a daily basis.
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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 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
04/25/2023 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230425082059

FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WILCOXFACILITY NUMBER:
198601943
ADMINISTRATOR:JUAN RAMIREZFACILITY TYPE:
735
ADDRESS:8134 WILCOX AVETELEPHONE:
(562) 447-0991
CITY:CUDAHYSTATE: CAZIP CODE:
90201
CAPACITY:3CENSUS: 3DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Raymundo LopezTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident threatens other residents and staff.
INVESTIGATION FINDINGS:
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In regards to the allegation Resident threatens other residents and staff, based on interviews conducted and information gathered Client C 1 said she has no arguments with other residents.
Client C 2 stated that with behaviors staff will watch to make sure it doesn't get bad. They make sure the house is run right. Stated Client C1 has behaviors and staff handle it well.
Staff interviewed stated that they track the behavior and will relocate residents to their rooms.
She has not hit anyone. Staff also would assist residents to go outside and would de-escalate her.
Due to interviews C1 has made homicidal threats to other clients and staff and is physically aggressive requiring police involvement.
Based on observations and interviews which were conducted, and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency cited on the 9099 D.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 28-AS-20230425082059
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 - WILCOX
FACILITY NUMBER: 198601943
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
80072(a)(1)(2)
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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.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs
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Administrator will ensure all residents are to be accorded dignity in his/her personal relationships with staff and other persons. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible threats. Plan will be submitted to LPA by POC due date.
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This requirement is not met as evidenced by:
Due to interviews C1 has made homicidal threats to other clients and staff and is physically aggressive requiring police involvement which poses an immediate health and safety risk to the residents 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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5