198602076-11-2-2023-28-AS-LHIS-CXEPGK-20231109101829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602076
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:23:35 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
10/26/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231026090745

FACILITY NAME:	EMPOWER UNLIMITED POTENTIAL		FACILITY NUMBER:	198602076
ADMINISTRATOR:	RAMIREZ, ELLISSET		FACILITY TYPE:	775
ADDRESS:	6713 SEVILLE AVE		TELEPHONE:	(323) 770-4440
CITY:	HUNTINGTON PARK	STATE: CA	ZIP CODE:	90255
CAPACITY:	50	CENSUS: 36	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ellisset Ramirez		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not adequately supervise clients resulting in inappropriate interactions between clients.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with Administrator Ellisset Ramirez.

The investigation consisted of the following: A tour of the facility was conducted. Staff (S1- S4) and clients (C1- C5) were interviewed. Client files were reviewed. Copies of Resident (R1's) file documents [Identification and Emergency Information/Face Sheet, Regional Center Individual Program Plans (IPPs), Physician Reports, Behavior Evaluation Reports, Case Note (10/12/23), SIR dated 10/12/2023, client and staff rosters were obtained.

***Narrative continues next page.***

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231026090745

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: EMPOWER UNLIMITED POTENTIAL	FACILITY NUMBER: 198602076
	VISIT DATE: 11/02/2023

NARRATIVE

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Allegation: Staff did not adequately supervise clients resulting in inappropriate interactions between clients. It is alleged that on October 12, 2023, clients went to volunteer to the LA Food Bank as a day program community outing activity. While at the food bank it is alleged that client (C2) made fun of client (C1) and called him inappropriate sexual names and then proceeded to touch C1's genitalia private area. The incident occurred during a restroom break. A total of five (5) clients were interviewed. Two (2) out of the five (5) clients interviewed stated that client (C2) has inappropriately touched them. Client (C1) stated the incident occurred outside the restroom, as client (C2) was walking out. Client (C1) told C2 "No, stop it" and C2 laughed and proceeded to touch C1 a second time. Client (C1) did not notify the two staff (S1 & S2) that were responsible for supervision of the two groups (total of 6 clients). The client/staff ratio is 3 to 1. Client (C2) was interviewed and revealed that they did touch C1 in their private part and staff did not see the incident. Client (C2) stated that it was done in a playful manner and proceeded to say that they play around with other clients too. Client (C2) confirmed the incident happened outside the restroom. Client (C2) stated that when staff asked about the incident they were not truthful because they do not want to be in trouble. Client (C3) stated that during a community outing to the park last week, C2 touched C3's back in a sexual inappropriate way. C3 stated that C2 "sexually harassed me." Client (C3's) initial reaction was to hit C2, but they did not. Client (C3) did not report the incident to staff and feels there is enough staff supervision.

A total of four (4) staff were interviewed. Staff (S1) and staff (S2) went to the food bank with the clients the day the incident occurred. Both staff (S1 & S2) stated they did not have any knowledge of the alleged incident. However, both S1 & S2 stated that client (C2) is known to say inappropriate comments out loud. On the day of the incident, male staff (S1) escorted the four (4) clients to the restroom during their break. The female staff (S2) stayed with the female clients in the table distribution area. According to all staff, they have not observed C2 inappropriately touch any clients, nor have any clients reported inappropriate touching and/or sexual harassment done by C2. Staff were notified of the incident the following day when C1's mother called to complain. Administrator stated that the clients were separated into different groups and are no longer going out on outings together. In addition, the day program notified C1 and C2's parents of the incident, and have requested an interdisciplinary meeting with the Regional Center and responsible parties.
Staff interviews revealed that client (C2) says vulgar things. Per record review, C1 has history of story fabrication, and client (C2's) documents do not indicate history of sexual misconduct. However, client (C2) admitted they touched C1 inappropriately. Therefore, there is sufficient evidence to corroborate the allegation.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted with Administrator Ellisset Ramirez. A copy of the report and appeal rights were issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20231026090745

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: EMPOWER UNLIMITED POTENTIAL	FACILITY NUMBER: 198602076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/02/2023 Section Cited CCR 82065(a)	1 2 3 4 5 6 7	Personnel Requirements. Program personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to: 1. Submit a written plan as to what steps will be taken to ensure that 1 direct care staff for every 3 clients is always met by tomorrow. 2. Administrator shall submit proof of staff training pertaining to regulation 82605 and submit to CCL by 11/9/2023.
	8 9 10 11 12 13 14	Based on interviews conducted, on 10/12/2023 during a community outing C1 was inappropritely touched in their private parts by C2, during their restroom break. The incident occurred outside the restroom with no staff present, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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