198602208-8-15-2025-28-AS-DSIS-DL8PEC-20250905111453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602208
Report Date: 08/15/2025
Date Signed: 08/15/2025 01:43:50 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
07/31/2025 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250731132328

FACILITY NAME:	ELEANOR RICHARDSON HOME		FACILITY NUMBER:	198602208
ADMINISTRATOR:	HOLLAND, TRAVIS		FACILITY TYPE:	735
ADDRESS:	462 E GROVE ST		TELEPHONE:	(909) 398-4488
CITY:	POMONA	STATE: CA	ZIP CODE:	91768
CAPACITY:	3	CENSUS: 3	DATE:	08/15/2025
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Jose Alderete - Administrator Kolresha Colbert - Care Staff		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff speaks inappropriately to resident.
Staff denies residents access to food and drink.
Staff do not ensure residents have access to clean drinking water.
Staff do not ensure facility is in good repair.
Staff do not ensure resident has clothing in good repair.
Staff do not ensure residents have adequate hygiene products.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint investigation for the allegations listed above. LPA met with Kolresha Colbert, Care Staff and explained the purpose of the visit. Shortly after, Jose Alderete, Administrator arrived and assisted LPA with the investigation.
The investigation consisted of the following: On 08/07/2025, LPA toured the facility and inspected Client #1 (C1) - Client #3 (C3)'s bedrooms, focusing on C2's, bathroom #2 in C2's bedroom, personal hygiene, cleaning/laundry supplies, water and food supplies. LPA interviewed Staff #1 (S1) - Staff #2 (S2) and Client #3 (C3). LPA attempted to interview C1-C2 but unsuccessful due to their cognitive abilities. LPA reviewed and obtained copies of the following files: latest staff training logs for zero tolerance policy, clients rights, abuse, mandatory reporting, Incident reports, Receipts for food, water, personal hygiene and cleaning supplies (June - Aug 2025), Service report/invoices for plumbing service and relevant files pertaining to Client #1 (C1) - Client #2 (C2). LPA also requested contact information for the Service Coordinator/QA Rep at San Gabriel Pomona Regional Center.
During today’s visit, LPA obtained staff & client rosters, facility menu,and interviewed Staff #3 (S3) - Staff #4 (S4). LPA conducted another tour of the facility’s kitchen and observed food supply which was inadequate at the initial visit. *****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: 08/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025

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 7

Control Number 28-AS-20250731132328

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: ELEANOR RICHARDSON HOME	FACILITY NUMBER: 198602208
	VISIT DATE: 08/15/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff speaks inappropriately to resident. It is alleged that a staff member uses racial slurs against a client and has also called the client a jackass. All staff interviewed denied the allegation. Staff members interviewed indicated they have not used offensive language toward clients. Staff also state dthat they treat clients with respect. S3 stated that they have not heard this allegation before, and none of the staff has reported this to them. C3 interviewed denied the allegation and stated that they had not heard any staff use racial slurs or refer to any client as a jackass. C3 indicated that staff treat them with respect and have not used inappropriate language with them. Therefore, there was insufficient evidence to corroborate with the allegation.

Allegation: Staff denies residents access to food and drink. It is alleged that a staff member prevents the clients from accessing the fridge or pantry when they want extra food or a drink and makes them go to their room. Staff interviewed denied the allegation and stated that clients have the right to choose what they want to eat and they encourage them to choose healthier snack options. Some staff interviewed stated that if clients refuse to eat what’s offered on the daily menu, they may select other food items from the refrigerator or freezer. C3 stated that there is a meal chart that is followed, and that if C3 does not like the meal for the day, staff will provide them with an alternative, but with very few options. Therefore, there was insufficient evidence to corroborate with the allegation.

Allegation: Staff do not ensure residents have access to clean drinking water. It is alleged that the facility does not have bottled water for the clients and management has instructed staff to give clients unfiltered tap water, which looks gray and cloudy. Some staff interviewed stated that they provide clients with unfiltered tap water by filling a jug and storing it in the refrigerator. Some staff interviewed stated that the gallon of water kept in the pantry is just for emergencies. Interview with C3 revealed that they told the administrator that they did not want to drink the tap water because it was unfiltered. C3 said that they buy their own water and keep it in their room. LPA observed that there were only (4) gallons of water kept in the pantry for emergency purposes only. LPA also observed that the water the clients drink comes from an unfiltered kitchen tap which did not appear to be cloudy. LPA did not see any reports or records of any illnesses related to drinking tap water. Therefore, there was insufficient evidence to corroborate with the allegation.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 28-AS-20250731132328

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: ELEANOR RICHARDSON HOME	FACILITY NUMBER: 198602208
	VISIT DATE: 08/15/2025

NARRATIVE

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Allegation: Staff do not ensure facility is in good repair. It is alleged that a client’s bathroom has been out of service since 07/28/2025, due to plumbing problems at the facility. Additionally, the client’s toilet sometimes overflows, which causes flooding, and this has happened twice in the last month and a half. Staff interviewed stated that the water overflowed onto the side every time the toilet flushed, causing the bathroom at C2 to flood several weeks ago. Staff also stated that the problem happened a few times because C2 likes to throw things like cloth towels which caused the toilet to become clogged. Staff interviewed stated that the plumber came at least twice to fix the toilet in C2's bathroom. C3 stated that the water entered the walls of their room, causing it to flood and confirmed that the plumber came to fix the toilet in C2's bathroom. LPA reviewed the plumber's service report (dated 06/19/2025 and 07/03/2025) which showed that the toilet pipe had been repaired. Therefore, there was insufficient evidence to corroborate with the allegation.

Allegation: Staff do not ensure resident has clothing in good repair. It is alleged that a client has clothes that don't fit and are also stained and ripped. And that sometimes, a staff member brings the client ‘s clothes they no longer need. Interviewed staff stated that they routinely check clients’ clothing and remove clothes that doesn't fit or has holes or rips. S1 stated that some of C2's clothes that didn't fit was taken to be donated with the consent of the Administrator and the clients. S3 stated that C2 has a habit of holding on to their belongings, like clothing as a source of comfort. C3 cannot comment on the allegation as he does not pay attention to the clients’ clothing. LPA did not observe stains or rips on C2's clothing. Therefore, there was insufficient evidence to corroborate with the allegation.

Allegation: Staff do not ensure residents have adequate hygiene products. It is alleged that the facility often runs out of dish detergent and personal hygiene supplies for the clients and management don't bring the supplies right away. Staff interviewed denied the allegation and stated that they never ran out of cleaning and personal hygiene supplies. However, if the supplies are low in inventory, the staff informs the Administrator, who will bring it over the next day. C3 indicated that the facility ran out of supplies sometimes, particularly laundry soap since staff have to wash clothes every day. C3 stated that they purchase some of their own personal hygiene items because they prefer a certain brand. LPA observed a few hygiene products and cleaning supplies in the storage cabinets. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with staff, client, review of clients 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 was conducted with Jose Alderete, Administrator. A copy of the report was provided to Kolresha Colbert, Care Staff.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
07/31/2025 and conducted by Evaluator Bennette Pena

COMPLAINT CONTROL NUMBER: 28-AS-20250731132328

FACILITY NAME:	ELEANOR RICHARDSON HOME		FACILITY NUMBER:	198602208
ADMINISTRATOR:	HOLLAND, TRAVIS		FACILITY TYPE:	735
ADDRESS:	462 E GROVE ST		TELEPHONE:	(909) 398-4488
CITY:	POMONA	STATE: CA	ZIP CODE:	91768
CAPACITY:	3	CENSUS: 3	DATE:	08/15/2025
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Jose Alderete - Administrator Kolresha Colbert - Care Staff		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff physically abuses resident.
Staff do not ensure facility has an adequate food supply.
Staff do not ensure facility is maintained at a comfortable temperature for residents.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025

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

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 28-AS-20250731132328

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: ELEANOR RICHARDSON HOME	FACILITY NUMBER: 198602208
	VISIT DATE: 08/15/2025

NARRATIVE

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Allegation: Staff physically abuses resident. It is alleged that a staff "karate chops" and kicks a client in the leg. (4) out of (4) staff interviewed denied the allegation. Interviewed staff stated that they had never witnessed or heard of a staff member "karate chopping" or kicking a client in the leg. Staff indicated that they are trained in abuse and clients’ rights and know that they are not allowed to hurt clients. C3 denied the allegation and stated that they had never witnessed any staff treating any clients in this manner. C3 indicated that the staff treat them with respect and that they feel safe at the facility. LPA did not observe any bruises or signs of injuries to C1-C3. Therefore, there was sufficient evidence to corroborate with the allegation.

Allegation: Staff do not ensure facility has an adequate food supply. It is alleged that the facility runs out of food every couple of days. Some staff interviewed stated that grocery shopping is done weekly. However, S1 stated that if they ran out of food, it was because the new staff did not follow the meal schedule, let the clients choose what they wanted to eat and overfed them.C3 stated that if they ran out of food, staff will either buy food for the clients or try to prepare something using what’s left in the refrigerator/freezer. Additionally, C3 stated that some staff would buy food for the clients and C3 buy groceries from their own pocket. Interviewed client indicated that the availability and variety of the food provided to them are not satisfactory. During the visit, LPA observed inadequate food in the refrigerator, food pantry/snack storage areas. Therefore, there was sufficient evidence to corroborate with the allegation.

Allegation: Staff do not ensure facility is maintained at a comfortable temperature for residents. It is alleged that a client’s room is hot, over 80 degrees, has no ventilation or fan, and the client wakes up sweating. Staff interviewed stated that the a/c control may be controlled via an app on the Administrator’s phone. But when staff contact the Administrator, sometimes it takes a while for him to respond, hence the a/c cannot be turned on right away. S3 stated that he is the only one who has control on the a/c sytem at the facility and controls it via an app on his phone. S3 also stated that the temperature in the facility is not in auto setting to a particular temperature. C3 did not have a comment on the temperature in the facility. LPA observed that at 12:20pm, the temperature in C2's room was hot and there was no ventilation. LPA and the staff tried to open the door in C2’s bedroom that leads to the backyard but failed to open. Therefore, there was sufficient evidence to corroborate with the allegation.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies cited on the attached LIC 9099D. An exit interview was conducted with the Administrator, Jose Alderete. A copy of this report was provided to Kolresha Colbert, Care Staff along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 28-AS-20250731132328

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: ELEANOR RICHARDSON HOME	FACILITY NUMBER: 198602208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 08/16/2025 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	80072 Personal Rights..(a),, each client shall have personal rights...(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions.... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to conduct an abuse, clients rights, mandatory reporting and zero tolerance policy training to all staff. Administrator will submit an in service training log as proof to CCL/LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews, the Administrator did not comply with the section cited above in which (2) staff members corroborated the allegation and reported it to the administrator months after the incident happened which poses a immediate Health, Safety, or Personal Rights risk to clients 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 28-AS-20250731132328

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: ELEANOR RICHARDSON HOME	FACILITY NUMBER: 198602208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 08/18/2025 Section Cited CCR 80076(a)(1)	1 2 3 4 5 6 7	80076 Food Services..(a) In facilities providing meals to clients, the following shall apply:(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator submitted copies of the grocery receipts to LPA. Administrator agreed to conduct a meeting with staff regarding managing food supplies. **DEFICIENCY CLEARED DURING THE SUBSEQUENT VISIT.***
	8 9 10 11 12 13 14	Based on interviews, observations, the Administrator did not comply with the section cited above in which the facility did not have adequate food and bottled water supply which poses a potential Health, Safety, or Personal Rights risk to clients in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 08/22/2025 Section Cited CCR 80088(a)	1 2 3 4 5 6 7	80088...Furniture, Fixtures, Equipment, and Supplies..(a) A comfortable temperature for clients shall be maintained at all areas. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to set the temperature in auto setting and will develop a plan to set a comfortable temperature setting agreeable to staff/clients. Administrator will submit this plan to CCL/LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews, observations, the Administrator did not comply with the section cited above in which C2's room did not have ventilation or fan and temperature in the facility can be hot to clients at times, which poses a potential Health, Safety, or Personal Rights risk to clients in care.	8 9 10 11 12 13 14

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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025

LIC9099 (FAS) - (06/04)

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