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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602422
Report Date: 12/26/2024
Date Signed: 12/26/2024 11:58:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/19/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241219210621
FACILITY NAME:PEOPLE'S CARE VIOLAFACILITY NUMBER:
198602422
ADMINISTRATOR:HUENDY MORAFACILITY TYPE:
737
ADDRESS:1605 VIOLA PLTELEPHONE:
(909) 671-4184
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY:3CENSUS: 3DATE:
12/26/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Christian RodriguezTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Staff did not report incidents in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation visit for the allegation listed above. LPA met with Administrator Christian Rodriguez and the purpose of the visit was discussed.

During this visit, LPA conducted a tour of this facility. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA interviewed Staff #1-3 (S1-S3) and Client #3 (C3). Client #1-#2 (C1 and C2) were not available for interview. LPA reviewed and collected copies of the staff and client roster. LPA also reviewed documents from the clients placement agency San Gabriel/Pomona Regional Center (SGPRC) related to the allegation above. The investigation revealed the following:

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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-20241219210621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PEOPLE'S CARE VIOLA
FACILITY NUMBER: 198602422
VISIT DATE: 12/26/2024
NARRATIVE
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In regards to the allegation "Staff did not report incidents in a timely manner" it is alleged that the facility did not follow reporting requirements regarding incidents on 11/3/24 and 11/5/24 involving C1. (2) of (3) Staff interviewed corroborated the allegation. (1) of (1) Client interviewed could not corroborate the allegation. Interviews with staff showed there was an incident on 11/3/24 that required a two (2) person standing support for C1 during an incident of physical aggression. There was another incident on 11/5/24 that required C1 to make a visit to the hospital. File review does not show that there were incidents reports provided to Licensing for both dates although both incidents are reportable incidents. Staff interviewed stated to not have created the incident reports for those dates during that month. The issue was also investigated by SGPRC and a Corrective Action Plan (CAP) was created for the facility. This shows the facility failed to meet Licensing reporting requirements as there was no written report provided within 7 days of each incident occurring. Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, Plan of Correction, and appeal rights were discussed and provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241219210621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PEOPLE'S CARE VIOLA
FACILITY NUMBER: 198602422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2025
Section Cited
CCR
80061(b)(1)(E)
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80061. Reporting Requirements(b) Upon the occurrence, during the operation of the facility...a report shall be made to the licensing agency within the agency's next working day... written report ... shall be submitted to the licensing agency within seven days
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Facility to conduct in-service training regarding Title 22 reporting requirements and also create missing incident reports for dates 11/3/24 and 11/5/24. Faciltiy to provide proof and copies to licensing by POC due date.
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This was not met as evidenced by there were no incident reports observed to be created for dates 11/3/24 and 11/5/24 involving incidents needed to be reported. This poses a potential health and safety risk to clients in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3