198602019-1-12-2024-28-AS-RORN-CZTSFG-20240125125020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602019
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:43:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/08/2023 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230908115817

FACILITY NAME:	PEOPLE'S CARE COVINA HILLS		FACILITY NUMBER:	198602019
ADMINISTRATOR:	RAMOS, JOLLIEREY (JOLLIE)		FACILITY TYPE:	735
ADDRESS:	1412 E COVINA HILLS RD		TELEPHONE:	(626) 498-0075
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	4	CENSUS: 3	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Jollie Ramos - Administraor		TIME COMPLETED:	03:57 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff improperly restrained a resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit in regards to the allegation listed above. LPA met with Jollie Ramos and explained the purpose of the visit.

The investigation consisted of the following: during the initial visit conducted on 9/12/2023, LPA Ashley Calderon conducted a tour of the facility, interviewed with Staff #1 (S1), obtained the Client and Staff rosters, obtained Client #1's (C1's) facesheet, identification and emergency form, latest IPP, and latest Progress Note/ Behavior Plan, and also obtained Crisis Prevention Intervention (CPI) training for Staff #3 (S3) and Staff #4 (S4) and a Special Incident Report of the incident. During today's visit, LPA Erik Zaragoza interviewed Clients 1 - 3 (C1 - C3), and Staff #2 - 6 (S2 - S6)

The investigation revealed the following: in regards to the allegation "Staff improperly restrained a resident in care", it is alleged that C1 was improperly restrained by S3 and S4 following an altercation between the parties.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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 2

Control Number 28-AS-20230908115817

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEOPLE'S CARE COVINA HILLS	FACILITY NUMBER: 198602019
	VISIT DATE: 01/12/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During interviews with the clients, one (1) out of three (3) corroborated the allegation that C1 was improperly restrained by staff. One client that was interviewed explained that during the incident, S4 dropped on top of C1 in order to improperly restrain C1 following a disagreement between C1 and the staff. Another client interviewed stated that they do not recall an incident of C1 being improperly restrained, an d that they have never had any issues with staff. During interviews with staff members, none of them corroborated the allegation that C1 was improperly restrained. One of the staff interviewed explained that the incident occurred after C1 requested to take a television from another client's room, and staff explained to C1 that they were not able to provide C1 with another clients property. This agitated C1 and led to C1 become aggressive, including throwing canned food cross rooms and tearing items from the walls. This led to S3 and S4 to attempt a CPI hold due to C1 becoming a danger to themselves and others. When S3 and S4 attempted to initiate the CPI hold, C1 intentionally fell to the ground and began kicking and flailing about, which caused both S3 and S4 to fall as well and land partially on C1. S5 entered the room in which the altercation was occurring and began verbally redirecting C1, and after doing so C1 eventually became calm. LPA reviewed C1's records including C1's Individualized Program Plan (IPP) and Physician's Report which revealed that C1 does have dangerous propensities including a history of property damage, physical aggression, and verbal aggression. Additionally, record review revealed that both S3 and S4 have current and valid CPI training that does not expire until May and March of 2024 respectively.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2