198602097-7-26-2023-11-AS-MVAO-CUCU8D-20230803152123

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602097
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:00:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
10/03/2022 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221003174743

FACILITY NAME:	INCLUSION SPECIALIZED PROGRAMS LLC - MANOR		FACILITY NUMBER:	198602097
ADMINISTRATOR:	PANTALEON, CECILIA		FACILITY TYPE:	735
ADDRESS:	13916 MANOR DR		TELEPHONE:	(424) 374-4165
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	3	CENSUS: 3	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator Cecilia Pantaleon		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff are physically abusive towards resident's.
Staff yells at resident's.
Facility illegally evicted resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #3 (S3: Michael Bandela) and was later met by Administrator (Cecilia Pantaleon). LPA/RA conducted a risk assessment with Staff #3 prior to entering the facility and observed COVID-19 protocol. A1 informed LPA/RA that the facility has no COVID cases nor do any of the clients or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation(s).

An initial 10-Day visit was conducted by LPA Martessa Brown on 10/12/22 with Asst. Administrator (A2: Jennifer Torres) and Staff #1 (S1: Margarita Olivares, House Manager). During the visit, LPA conducted a tour of the facility’s physical plant with Staff #1 to ensure the wellbeing of the clients. LPA/RA Ceniceros interviewed (between 11:15 a.m. - 2:30 p.m). three (3) staff members and one (1) client and one (1) witness. LPA/RA reviewed (between 12:45 p.m. – 1:00 p.m.) the requested documents: staff/client roster, incident report related to the above-mentioned allegations, Staff #1-#3 training records; Client #1’s face

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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-20221003174743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - MANOR	FACILITY NUMBER: 198602097
	VISIT DATE: 07/26/2023

NARRATIVE

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sheet, admission agreement, IPP, and progress notes, Physician’s Report, hospital medical records, and any local enforcement reports.

Regarding Allegation #1: this investigation revealed based on interviews conducted of facility staff (A1, A2, A3, A4) four (4) of the four (4) staff members corroborated that they were present when the incident occurred on 12/15/21 regarding Client #1 being brought back to the facility - following a health condition at the adult day program. Facility staff immediately observed Client #1’s health condition and made attempts to call the client to receive a response; however, the client couldn’t stand up and appeared to be lethargic and unresponsive. Facility staff immediately called 9-1-1 and the client was transported (via ambulance) to the hospital. Hawthorne Police responded to the facility to conduct a welfare check, but there was no report or incident. Facility staff deny being physically abusive towards Client #1; as a result of facility staff observing and attempting to assist the client condition during their health condition on 12/15/21. RA Ceniceros interviewed one (1) of the three (3) clients who corroborated that facility staff have never been physically abusive towards the client nor has client witnessed facility staff being physically abusive towards the other clients in care. A review of facility staff training records documented staffs’ last “Personal Rights” training was conducted on 07/30/21.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are physically abusive towards resident's is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted of facility staff (A1, A2, A3, A4), four (4) of the four (4) staff members corroborated that they have not yelled or witnessed another staff member yelling at the clients in care. Facility staff stated that the complaint allegations were filed far after this incident had occurred on 12/15/21. Client #1 would continuously return to the facility and would show up outside of the facility and begin displaying behaviors and later Hawthorne Police responded to the facility to conduct a welfare check, but there was no report or incident. RA Ceniceros interviewed one (1) of the three (3) clients who corroborated that facility staff have never yelled at client nor witnessed facility staff yelling at the other clients in care. A review of facility staff training records documented staffs’ last “Personal Rights” training was conducted on 07/30/21.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20221003174743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - MANOR	FACILITY NUMBER: 198602097
	VISIT DATE: 07/26/2023

NARRATIVE

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have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff yells at resident’s is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed based on interviews conducted of facility staff (A1, A2, A3, A4) that an incident had occurred on 12/15/21 with Client #1 (C1) who suffered a stroke at their adult day program (Liberty Day Program); and, the client was transported to the hospital (Little Company of Mary) via 9-1-1. Client #1 was discharged from the hospital – following surgery and transferred to a skilled-nursing facility. Witness #2 (W2: Marquieda Limbrick, WRC Service Coordinator) placed Client #1 at another regional center facility due to a higher level of care. Witness #2 (W2: Ellen Lao, WRC Quality Assurance) confirmed that this facility is a CPP (Community Placement Plan – Level 4-I) and not a medical facility. RA Ceniceros interviewed one (1) of the three (3) clients who corroborated that facility staff have never evicted the client nor has the client witnessed facility staff evicting a client in care. A review of facility staff training records documented staffs’ last “Personal Rights” training was conducted on 07/30/21.

Administrator confirmed Hawthorne Police did respond to the facility on 12/15/21 to conduct a welfare check, but no report or incident.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of EVICTION/DISCHARGE: Facility illegally evicted resident is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Administrator (Cecilia Pantaleon).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

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