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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602422
Report Date: 08/15/2025
Date Signed: 08/15/2025 03:41:17 PM

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
02/11/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250211125725
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:
08/15/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Marc Marquez - staffTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff did not follow the facility IPP resulting in client ingesting a foreign object.
Staff did not have the required training.
Staff did not provide medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent visit to investigate the above allegations. LPA met with Marc Marquez. Shortly after Administrator Jasmine Zamora arrived who assisted with the visit. Purpose of todays visit was discussed. Jasmine Zamora is the Administrator for the facility since 07/01/25.

On 02/18/25, LPA Margaryan conducted the initial investigation and met with Chris Rodriguez, Administrator. During this visit, LPA obtained a copy of the Client Roster, a copy of the Staff Roster, interviewed Facility Administrator and Staff 1 (S1) and Quality Assurance Specialist (QAS) from SGPRC. LPA reviewed Client 1's (C1) file and obtained relevant documentation. LPA was unable to interview C1. C1 was at the hospital at the time of visit.
Continue 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
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 6
Control Number 28-AS-20250211125725
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: 08/15/2025
NARRATIVE
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During this investigation, LPA interviewed Former Administrator, Current Administrator, QA, Staff 1 (S1), Staff 3 (S3) and Staff 4 (S4). S4 interviewed over the phone. LPA was unable to interview Staff 2 (S2) as S2 no longer work at this facility. LPA reviewed C1’s file and obtained relevant documentation. LPA was unable to interview Client 1 (C1) through Client 3 (C3). C1 refused to be interviewed and C2 and C3 were at Day Program at the time of visit. Additionally, San Gabriel Pomona Regional Center also conducted an investigation in regards to these incidents.

Allegation: Staff did not follow the facility IPP resulting in client ingesting a foreign object. Interviews conducted and reviewed documentation revealed that on 12/05/24 C1 swallowed / ingested the metal plug of heating pad and on 01/20/25 C1 swallowed a dime during the outing at the store which confirmed by an x-ray examination. According to C1s IPP, C1 has a “PICA – like behavior: Inserting any item (pieces of plastic, batteries, coins, small metal objects, etc. that is not meant to be consumed into C1’s mouth (may or may not swallow objects)”. Per documentation, C1 requires supervision at all times. LPA review Individual Behavior Support Plan which stated “The 2:1 staffing ratio will be maintained throughout all three shifts (AM, PM, and NOC). During each shift, two staff members will be assigned exclusively to C1, both in the facility and in the community. Staff members must always maintain a line of sight with C1, never exceedingly more than eight feet away from C1. When C1 is in common areas, both staff members should be present and maintain visual contact”. Interviewed QA confirmed that facility staff did not follow C1’s individual Behavior Support Plan and as a result C1 ingested foreign items on 2 separate occasions. Interviews conducted and reviewed documentation corroborates this allegation as C1 ingested foreign items on 2 separate occasions which are noted above.

Continue 9099C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
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 6
Control Number 28-AS-20250211125725
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: 08/15/2025
NARRATIVE
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Allegation: Staff did not have the required training. Interviews conducted and reviewed documentation revealed that on 12/05/24 and on 01/20/25 C1 swallowed / ingested metal plug of heating pad and a dime which confirmed by an x-ray examination. Per former Administrator’s interview after 12/05/24 there was a training held on 12/11/24. They focused on the supervision policies and procedures for clients, emphasizing the importance of maintaining a 2:1 staff ratio and ensuring a continuous line of sight supervision. Training also addressed managing high risk behaviors and self injurious behaviors or actions, maintained safety in the facility and in community settings. However, some of the staff did not participate in the training courses, including S1 and S2. Copies of In-Service Training Record was provided to LPA at the time of initial visit. Interviewed QA confirmed that not of all facility staff provided training and did not follow C1’s individual Behavior Support Plan and as a result C1 ingested foreign items on 2 separate occasions. Interviewed Administrator (current) stated that in service training provided to all staff. Copies of the training materials and signing sheets were provided to LPA. Interviews conducted and reviewed documentation corroborates this allegation.

Allegation: Staff did not provide medication as prescribed. Interviews conducted and reviewed documentation revealed that medication errors were reported to SGPRC on 11/29/24 and on 12/10/24. Staff failure to dispense medication as prescribed by a physician. San Gabriel Pomona Regional Center's unannounced visits on 12/3/24 and 12/11/24 revealed the medication error and in the Corrective Action Plan dated 12/12/24 a substantial Inadequacy and citation was issued for failure to administer medication as prescribed. Interview with Administrator and staff confirmed the medication error. Interviewed Former Administrator confirmed that there were medication errors and SIRs were sent to CCLD. Copies of SIRs were provided. Former Administrator stated that per physician's order, C1 needs to take Risperidone 2mg twice a day at 8am and 5pm. However on 11/29/24 S4 dispensed an extra dosage of Risperidone 2mg. Interviewed S4 confirmed that there was a incident that they dispensed an extra dosage of medication to the client. On 12/09/24 S3 discovered that MAR was not initiated for C2, 11pm scheduled Amoxicillin. S3 then checked the centrally stored medication and discovered it was not passed on the scheduled time by S2. Interviews conducted and reviewed documentation corroborates this allegation.

Continue 9099C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
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 6
Control Number 28-AS-20250211125725
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: 08/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2025
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Licensee / Administrator provided copy of In-service training regarding Supervision and 8ft minimum requirement in line of sight completed on 02/06/25 per CAP dated 01/29/25.
**Deficiency cleared at time of visit.**
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Based on interviews, review of documents, CAP confirmed that C1 ingested foreign objects on different dates due to not being properly supervised, which poses an immediate risk of clients in care.
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Type A
08/15/2025
Section Cited
CCR
80075(b)(5)(B)
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80075 Health Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5)If the client's physician has stated in writing that the client is unable to.... providing all of the following requirements are met.
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In service training was provided to all facility staff. Copies of training materials and signing sheets were provided. Licensee / Administrator shall ensure once ordered by the physician the medication is given according to the physician's order.
**Deficiency cleared at time of visit.**
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 (B)Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:C1 - dispensed an extra dosage of Risperidone 2mg. C2 - scheduled Amoxicillin was not passed on the schedule time.This poses an immediate risk of 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
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: 4 of 6
Control Number 28-AS-20250211125725
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: 08/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
80065(f)
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Personnel Requirements. (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
This requirement is not met as evidenced by:
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In service training was provided to all facility staff. Copies of training materials and signing sheets were provided.
**Deficiency cleared at time of visit.**
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This requirement is not met as evidenced by: Based on interviews, review of documents, confirmed that some of facility staff including did not participate in the training courses, including S1 and S2 which poses a potential health, safety or personal rights risk to persons 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
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: 5 of 6
Control Number 28-AS-20250211125725
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: 08/15/2025
NARRATIVE
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 Interviewed Administrator (current) stated that they aware of the medication errors and in service training was provided to all staff. Copies of the training materials and signing sheets were provided. At the time of the visits LPA reviewed medications for all clients and did not see any medication errors.

Based on interviews conducted, records reviewed and review of CAP, the preponderance of evidence standard has been met, therefore the above stated allegations are found to be substantiated.

Please attached LIC 9099D.

Exit interview conducted with Jasmine Zamora, Administrator and a copy of this report and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
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: 6 of 6