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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602123
Report Date: 06/06/2023
Date Signed: 06/06/2023 01:26:00 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
06/01/2023 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230601113750
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:
06/06/2023
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Margie Kimble - AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Resident was threatened by another resident while in care due to lack of adequate supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10-day complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Abigail Reano, House Lead who screened the LPA upon arrival. LPA also met Margie Kimble, Administrator and explained the reason for the visit.

The investigation consisted of the following: LPA Pena obtained copies of Staff and Client Rosters, Special Incident Reports (SIRs) involving Client #3 (C3) dated 5/12/2023, 5/30/23 and 6/2/2023. LPA conducted an interview with Staff #1 (S1)-Staff #3 (S3), Client #1 (C1) – Client #2 (C2), and telephonically interviewed Staff #4 (S4) at 11:25am and RC Service Coordinator (SC) at 11:39am. LPA also obtained Client #3 (C3) files such as: Face Sheet, Physician's Report (11/04/2022), Admission Agreement, Appraisal/Needs Services Plan (10/01/2022), Functional Behavior Assessment (02/15/2023) and Progress Evaluation Report . LPA also toured the facility’s common areas and observed clients in care.
*****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
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 2
Control Number 28-AS-20230601113750
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: 06/06/2023
NARRATIVE
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The investigation revealed the following:

Allegation: Resident was threatened by another resident while in care due to lack of adequate supervision. It is alleged that another individual in the home has made threats to the client. It is also alleged that someone in the home told the client that if he was to return, they would kill him. Interviewed staff members denied any knowledge of the alleged incident and indicated that no one has threatened C3. (4) out of (4) staff members stated that it was C3 who was verbally abusive and has threatened to kill the staff. Staff members also indicated that C3 has a history of fabricating stories and suffers from self injurious behaviors (SIB) which were documented on the facility files. S1 stated that there was enough supervision to the clients and there are 2-3 staff present per shift. Interviews conducted with C2-C3 revealed that they never witnessed or heard any staff threatening to kill any clients who lived in the home. C2-C3 indicated that it was C3 who often screams and threatened to kill the staff. LPA reviewed the Special Incident Reports (SIRs) which indicated that C3 has engaged in verbal aggression and threatened to kill staff and himself. Review of the reports also indicated that C3 had behavioral episodes of SIB, which required verbal redirection and de-escalation from the staff. Interview conducted telephonically with SGP Regional Center SC revealed that he was not aware of this alleged incident and there was no incident report sent to their office regarding this. SC stated that he did not have any contact directly with C3 to get this information because he is out of the facility.

Based on statements and interviews conducted with clients, staff and SGP Regional Center SC as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.



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 is UNSUBSTANTIATED.

Exit interview and a copy of this report was provided to the House Lead, Abigail Reano.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2