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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601964
Report Date: 08/22/2024
Date Signed: 08/22/2024 04:33:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20240814161519
FACILITY NAME:HAZELBROOK HOMEFACILITY NUMBER:
198601964
ADMINISTRATOR:PEARL M LAMBFACILITY TYPE:
735
ADDRESS:4857 HAZELBROOK AVENUETELEPHONE:
(562) 452-7034
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:3CENSUS: 3DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Valerie GonzalezTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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On 08/22/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Program Director, Christy Serafico and Program Supervisor, Valerie Gonzalez, and the purpose of today’s visit was explained.

During today’s visit, LPA toured the facility, interview Staff S1-S7, interviewed Clients c1-C2, and received documents pertinent to the investigation. The documents received and reviewed include the Staff Roster, Client Roster, Staff Schelule, Monthly Training Calander for 2024, staff signed Mandated Reporting documents, Physician’s Report, Individual Person-Centered Plan (IPP), Individual Service Plan (ISP), ISP Nursing Assessment, and Behavior Assessment and Positive Behavior Support Plan.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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 3
Control Number 11-AS-20240814161519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAZELBROOK HOME
FACILITY NUMBER: 198601964
VISIT DATE: 08/22/2024
NARRATIVE
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Allegation: staff handled resident in a rough manner

The complaint allegation alleges that during a diaper change, a resident could be heard crying due to caregiver being rough.

During record review at the facility, LPA reviewed training logs and in-service logs for Mandated Reporting conducted on 04/11/24. LPA reviewed staff’s SOC341 which they signed stating they would report any suspected abuse. LPA received and reviewed Clients Physician Report and Individual Person-Centered Plan (IPP), stating C1 communicates their dislike of activities which are necessary to meet physical needs by vocalizing. During the facility visit, LPA observed C1 and C2 being assisted with changing and observed C1 and C2 vocalizing their dislike of the changing. LPA observed staff properly assisting clients during the changing. Additionally, LPA observed C1 being transferred from their bed to their wheelchair by staff using a Hoyer lift. During the transfer C1 was communicating their dislike of the transfer through vocalization.


During interviews with Staff S1-S7, were asked if they have or have observed staff handle client in a rough manner, six (6) out of seven (7) stated they have not nor have they observed staff handle clients in a rough manner. Additionally, during interviews with Staff S1-S7, were asked what they would do if they observed a staff handle a client in a rough manner, seven (7) out of seven (7) stated they would report it. During interviews with Staff S1-S7, were asked if they have heard a client cry while being assisted with changing, seven (7) out of seven (7) stated there are
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20240814161519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAZELBROOK HOME
FACILITY NUMBER: 198601964
VISIT DATE: 08/22/2024
NARRATIVE
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two clients who vocalize their dislike while being assisted with changing or being transferred.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated

During today’s visit, LPA did not observe any Health and Safety violations.

No deficiencies were observed or cited.

An exit interview was conducted with Program Supervisor, Valerie Gonzalez, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3