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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602123
Report Date: 01/28/2025
Date Signed: 01/28/2025 04:38:03 PM

Substantiated


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
01/22/2025 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250122092851
FACILITY NAME:PEOPLE'S CARE CAMERONFACILITY NUMBER:
198602123
ADMINISTRATOR:MARGIE KIMBLEFACILITY TYPE:
735
ADDRESS:2441 CAMERON AVETELEPHONE:
(626) 732-3500
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:4CENSUS: 3DATE:
01/28/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Margie Kimble, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff inappropriately restrained client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegation listed above. LPA arrived unannounced and met with Administrator, Margie Kimble. The purpose of the visit was explained.

LPA obtained copies of the staff and client rosters, gathered documents for Client #1 and Staff #1. Interviewed were conducted with the administrator, 2 Staff, and 2 Clients.

Allegation - Facility staff inappropriately restrained client. It is alleged that Staff #1 (S1) inappropriately restrained Client #1 (C1) in a "choke hold". LPA interviewed the administrator, staff, and clients regarding the incident that occurred on 1/17/25.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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-20250122092851
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 CAMERON
FACILITY NUMBER: 198602123
VISIT DATE: 01/28/2025
NARRATIVE
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Per the administrator, S1 admitted to pinning down C1 on the chest during their internal investigation. Another staff interviewed witnessed S1 barging into C1’s room without permission and confronting C1 about a situation that occurred earlier that day. S1 approached C1 aggressively which caused C1 to swing at the staff. Both parties fell on the bed and S1 then pinned client down with the right knee. S1 restrained C1 in that position until client reported he was calm. No injuries were observed on C1 that day, however, C1 reported pain on the neck and shoulder a few days later. C1 stated that staff held him down and admitted to swinging at S1. Other client stated that S1 is not respectful towards the clients at the home and uses a loud tone of voice when speaking to them.

Administrator stated the technique used by S1 is not allowed as part of their CPI training and staff had been coach/retrained regarding the approach with clients. Other staff interviewed indicated that S1 had spoken to clients inappropriately in the past and was reported to management. S1 has resigned and no longer working at the facility.

Based on interviews conducted, and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D.



An exit interview was conducted. A copy of this report and appeal rights were provided to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250122092851
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 CAMERON
FACILITY NUMBER: 198602123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a)...each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/hef personal relationships with staff and othe persons. This requirement is not met as evidenced by:
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Licensee shall ensure S1 receives proper training to handle clients' behaviors. The POC shall be submitted to LPA by 1/29/25.

**C1 has resigned and no longer working at the facility. POC is cleared.
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Based on interviews, S1 utilized inappropriate technque to restrain client which poses as an immediate health, safety, and personal rights risk to clients in care.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3