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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602017
Report Date: 07/08/2022
Date Signed: 07/08/2022 12:54:05 PM

Substantiated


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
11/03/2020 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201103120100
FACILITY NAME:PALACIOS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198602017
ADMINISTRATOR:PALACIOS, RAQUELFACILITY TYPE:
735
ADDRESS:1232 MILLBURY AVETELEPHONE:
(626) 338-0854
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:6CENSUS: 5DATE:
07/08/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Raquel Palacios- AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff used inappropriate form of discipline.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Maldonado made a subsequent unannounced complaint visit to the facility regarding the above-mentioned allegation. The initial visit was conducted telephonically by LPA Long on 11/10/20, who met with administrator Raquel Palacios. During today’s visit, LPA Maldonado met with Raquel Palacios, to explain the reason for the visit and toured the physical plant.

During the visit on 11/10/20, LPA Long interviewed Administrator staff# 1 (S1) and requested a copy of the client and staff roster.

On 07/07/21, LPA Maldonado conducted a telephone interview with S1 Administrator and requested the following documents for client# 1 (C1): face sheet, physician’s report, and IPP for 2020. A copy of the staff and client roster was also requested.

Report contiued on LIC9099-C...
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
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 28-AS-20201103120100
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: PALACIOS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198602017
VISIT DATE: 07/08/2022
NARRATIVE
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During today’s visit, LPA Maldonado conducted interviews with client# 1- client# 4 (C1-C5).

Allegation: Facility staff used inappropriate form of discipline. During the interview conducted with the administrator, it was discovered that C1’s crutches, which assist C1 with ambulation, per physician report dated 06/09/2021. C1's crutches were taken away by the administrator when C1's behaviors began increasing. Per Administrator C1 tends to hit staff or clients nearby and destroy property with C1's crutches. Administrator stated that when C1’s crutches were removed, C1 was sat on the bed and staff monitored until C1 was calm. Once calm, the Administrator returned the crutches to C1, but C1 was never left unsupervised while crutches were not in C1’s possession. During interviews conducted with C1-C5, it was discovered that staff treat clients nice. (4) of (5) clients state that staff have never take any of their personal belongings from them as form of punishment, or to assist them when they are having a crisis. The investigation revealed that staff took C1s crutches away from C1 when C1 was having behaviors and C1 cannot ambulate without crutches, which is a violation of C1's personal rights.

Based on LPA's observations, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found Substantiated. California Code of Regulations Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator Raquel Palacios. A copy of the licensing report and appeal rights were given to Administrator upon completion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20201103120100
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: PALACIOS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198602017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2022
Section Cited
CCR
80072(a)(3)
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Personal Rights
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including… aids to physical functioning.
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Licensee to send LPA a statement indicating they will adhere to Title 22 Section 80072- Personal Rights by POC deadline of: 07/13/22. The
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During the investigation, adminstrator admitted to removing C1's crutches any time heightened behaviors were displayed, as C1 would use crutches to hit staff or clients and destroyed property with them. This was a violation of C1's personal rights.
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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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3