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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602388
Report Date: 12/16/2025
Date Signed: 12/16/2025 01:07:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
04/25/2025 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250425085913
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA MOUNTAIN VIEWFACILITY NUMBER:
198602388
ADMINISTRATOR:ANDRES ROJASFACILITY TYPE:
735
ADDRESS:3799 MOUNTAIN VIEW AVETELEPHONE:
(818) 512-2494
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:4CENSUS: 4DATE:
12/16/2025
UNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Masoumeh Ho - LVN TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Lack of care and supervision resulted in client sustaining a second-degree burn.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Masoumeh Ho and explained the reason for the visit.

The investigation consisted of the following: On 4/28/25 LPA Flores conducted an initial complaint investigation visit, a health and safety check, and requested documents for client #1(C1). On 6/6/25 LPA Flores requested medical records. On 9/3/25 LPA Flores attempted to request medical records. On 10/20/25 LPA Flores requested assistance to request medical records from our Investigation Bureau (IB). On 11/26/25 LPA Flores received medical records. On 12/10/25 LPA Flores contacted Quality Assurance Specialist from San Gabriel Pomona Regional Center. On 12/16/25 LPA Flores delivered findings.

The investigation revealed the following: Regarding allegation: Lack of care and supervision resulted in client sustaining a second-degree burn. It is alleged C1 obtained second-degree burns in C1’s thighs due to neglect. (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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-20250425085913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA MOUNTAIN VIEW
FACILITY NUMBER: 198602388
VISIT DATE: 12/16/2025
NARRATIVE
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On 4/23/25 C1’s lunch was served at the dining room table along with another client. C1 was served hot soup, that C1 tilted into C1's lap, and resulted in 2nd degree burns. Staff #1(S1) provided first aid and staff #2(S2) contacted C1’s physician and sought medical care for C1. Interview conducted with staff #1(S1) revealed S1 prepared the soup in the stove, turned off the stove, proceeded to pour the soup into bowls, and served the soup to C1 by placing it in the dining table, in that order. As S1 placed the hot soup at the table client #2(C2), who was seated at the other side of the table requested S1’s assistance. S1 let C1 know the soup was hot and proceed to assist C2. As S1 was assisting C2, S1 heard the incident and proceeded to provide first aid to C1. Upon S2's arrival at the facility, S2 contacted the physician and sought C1 receive medical care. Documents review revealed, per Physician’s Progress Note dated: 4/13/25, C1 was observed with bilateral redness and blisters to the thighs due to 2nd degree burns. Per Individual Progress Plan dated: 5/15/23 C1 requires assistance with all activities of daily living. On 5/22/25 San Gabriel Pomona Regional Center conducted an investigation and substantiated the allegation. Based on the information reviewed C1 sustained injuries of 2nd degree burns with blisters in both thighs, facility did not have a plan to ensure food served to clients in care was not hot to avoid clients injuring themselves. Therefore, the allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) 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 immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM***

Exit interview was conducted with Ernesto Vasquez Director Residential Services an a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250425085913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA MOUNTAIN VIEW
FACILITY NUMBER: 198602388
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2025
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights: (a).., each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
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Administrator created a Safety Plan for Serving Hot Liquids and provided LPA Flores a copy on 12/10/25. Training on the plan was provided to staff on 5/2/25 and 8/20/25. Deficiency cleared as of 12/16/25.
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Based on interviews and document review conducted licensee did not ensure C1 did not sustained 2nd degree burns when S1 served hot soup which poses an immediate health, safety, or personal rights risk to the persons in care.
*Immediate $500 civil penalties assess*
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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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
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