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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602290
Report Date: 06/28/2022
Date Signed: 07/05/2022 08:52:41 AM

Substantiated


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
06/21/2022 and conducted by Evaluator Jey Cardenas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220621100907
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WEST 139THFACILITY NUMBER:
198602290
ADMINISTRATOR:RAFAEL CARBAJALFACILITY TYPE:
735
ADDRESS:4835 W 139TH STTELEPHONE:
(565) 447-0991
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:3CENSUS: 3DATE:
06/28/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Blanca MaciasTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff would not allow resident to have visits
Staff did not ensure a safe and healthful environment for residents by yelling in front of residents
Staff did not ensure a safe and healthful environment for residents by swearing in front of residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced initial-10day complaint visit to the above facility to initiate complaint investigation. Upon arrival at the facility LPA met with staff#3 and conducted a Covid-19 risk assessment, based on the assessment, the facility is clear of Covid-19 infection. LPA met with Back up administrator, Blanca Macias who assisted LPA; the purpose of the visit was explained.

Investigation consisted of: LPA conducted interviews with Blanca Macias, staff#2-Staff#4 (S2-S4), Client#1-Client#2 (C1-C2), tour of physical plant, and obtained facility documentation pertinent to the complaint allegation.

-Regarding allegations: Staff would not allow clients to have visits, Staff did not ensure a safe and healthful environment for clients by yelling In front of clients, Staff did not ensure a safe and healthful environment by swearing in front of clients. It is alleged that on 6/16/2022 S1 would not allow client visitors to come into the facility to visit with the client. S1 was heard yelling and swearing at the visitors at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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-20220621100907
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 - WEST 139TH
FACILITY NUMBER: 198602290
VISIT DATE: 06/28/2022
NARRATIVE
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(continued pg2)

Per interviews with Blanca Macias, she states that the facility has an open-door policy for visitors. They are allowed to visit at any time, as long as its within visitors’ hours. It is recommended that they call facility beforehand to make visiting arrangements, however, it is not required. Blanca stated that a couple of weeks ago she received a call from S1 who was yelling and swearing while on the phone. Clients visitors were at the facility and S1 wouldn’t allow them to come in. S1 reported to Blanca that the visitor had acted inappropriate in the past and she didn’t feel comfortable. Blanca states that C1 and C2 were in their bedroom and C3 was at day program during the incident. An incident report was not submitted to CCLD, and is unsure if a police report was filed. During interview with S2, staff indicates witnessing incident that took place on 6/16/22. S1 heard verbal altercation outside the facility. S2 then realized that S1 and client’s visitors were yelling and swearing at each other back and forth. Later, S1 and the visitors made their way inside the facility to the dinning room and continued yelling and swearing. During interview with S3, staff indicates that S1 would not allow the clients’ visitors in because they didn’t have an appointment. S1 and visitors were yelling and swearing at each other back and forth. During interview with C1, client reported S1 is disrespectful. C1 reported that a couple of weeks ago, client heard S1 yelling and swearing at visitors trying to come into the facility. S1 kept telling visitors that they needed an appointment to visit. S1 was loud and client could hear the yelling and swearing. C2 reports family is able to visit and didn’t hear any verbal altercation.

Based on LPA’s interviews, and record review(s), the preponderance of evidence standard has been met. Therefore, the allegations, are found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D.

Exit interview was conducted telephonic, appeal rights were discussed, and a copy of this report LIC9099 LIC9099D and appeal rights was provided via email due to computer malfunctions, LPM notified

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220621100907
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 - WEST 139TH
FACILITY NUMBER: 198602290
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2022
Section Cited
CCR
85072(b)(4)
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Personal rights- To have visitors, including advocacy representatives, visit privately during waking hours...This requirement not met as evidenced by: On 6/28/2022 LPA interviewed staff and client who corroborated allegations re: S1 denying client from having visitors.
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Administrator will conduct in-service training with all staff regarding Observing Clients' Rights for visitation. Administrator will send documentation of training to Licensing by POC due date.
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This poses a potential personal rights risk to clients in care.
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Type B
07/08/2022
Section Cited
CCR
80072(a)(2)
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To be accorded safe, healthful and comfortable accommodations, furnishings... This requirement not met as evidenced by: Per interviews with staff and client, On 6/16/22 S1 was heard yelling and swearing at clients visitors at the facility. This poses a potential person right risk to clients in care
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Administrator will conduct in-service training with all staff regarding Observing Clients' Rights for safe, healthful, comfortable environment for clients. Administrator will send documentation of training to Licensing by POC due date.
Type B
07/08/2022
Section Cited
CCR
80061(a)
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Reporting Requirements- Each licensee or applicant shall furnish to the licensing agency reports as required... This requirement not met as evidenced by: On 6/28/2022 Blanca confirmed a incident report for incident was not submitted to licensing. This poses a potential heath& safety risk.
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Administrator will submit unusual incident report to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3