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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601962
Report Date: 03/09/2021
Date Signed: 03/14/2021 01:30:19 PM



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
07/09/2020 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200709100758
FACILITY NAME:SOUTHLAND LIVINGFACILITY NUMBER:
198601962
ADMINISTRATOR:TRAN, VICTORIAFACILITY TYPE:
740
ADDRESS:11701 STUDEBAKER ROADTELEPHONE:
(562) 406-7326
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:75CENSUS: 44DATE:
03/09/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Victoria TranTIME COMPLETED:
12:07 PM
ALLEGATION(S):
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Resident was sexually assaulted while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Victoria Tran.

The investigation consisted of the following: CDSS investigations branch investigator Harmin Sandhu conducted an investigation which consisted of interviews with resident #1(R1), other agencies, Administrator, and obtaining documents. On 07/19/20 LPA Wesley requested a copy of the: staff roster, resident roster, and the Emergency Identification page(face sheet), currenty Physician's reports, as well as the current Appraisal Needs and Services plan for resident #1.

Continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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 2
Control Number 28-AS-20200709100758
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: SOUTHLAND LIVING
FACILITY NUMBER: 198601962
VISIT DATE: 03/09/2021
NARRATIVE
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Investigation revealed the following: regarding allegation: Resident was sexually assaulted while in care. CDSS IB Investigator Sandhu conducted and investigation which revealed the following: victim(R1) statements they provided to the police and hospital staff members were inconsistent. R1 told the hospital doctor that the incident occurred the night before, and they told the police the incident occurred two weeks ago. R1 alleged they were sexually assaulted by three black men, but there are no African American males employed at the facility. The hospital report noted there were no signs for sexual abuse. There is no evidence to support the allegation Resident was sexually assaulted while in care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Administrator Victoria Tran, and a hard copy was provided via email to obtain signature. There are no citations issued, exit interview conducted.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
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