198602388-1-7-2026-28-AS-WSHO-DQ6S7K-20260109123737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602388
Report Date: 01/07/2026
Date Signed: 01/07/2026 08:04:06 AM

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

COMPLAINT CONTROL NUMBER: 28-AS-20250425085913

FACILITY NAME:	EASTER SEALS SOUTHERN CALIFORNIA MOUNTAIN VIEW		FACILITY NUMBER:	198602388
ADMINISTRATOR:	ANDRES ROJAS		FACILITY TYPE:	735
ADDRESS:	3799 MOUNTAIN VIEW AVE		TELEPHONE:	(818) 512-2494
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	4	CENSUS: 4	DATE:	01/07/2026
		UNANNOUNCED	TIME BEGAN:	07:35 AM
MET WITH:	Sergio Calderon - LVN/Direct Support Staff		TIME COMPLETED:	08:20 AM

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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*This report supersedes report dated 12/16/25 to correct date of Physician's Progress Notes from 4/13/25 to 4/23/25 on LIC 9099C. Substantiated findings delivered on 12/16/25 remain the same.*
Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Sergio Calderon 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.

(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

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

LIC9099 (FAS) - (06/04)

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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: 01/07/2026

NARRATIVE

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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. 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: 4/23/25, 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 was issued on 12/16/25. Refer to LIC 421IM***

Exit interview was conducted with Sergio Calderon Direct Support Staff an a copy of this report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

LIC9099 (FAS) - (06/04)

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