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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602422
Report Date: 05/11/2026
Date Signed: 05/11/2026 04:51:10 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
05/01/2026 and conducted by Evaluator Gabriela Castro
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260501164858
FACILITY NAME:PEOPLE'S CARE VIOLAFACILITY NUMBER:
198602422
ADMINISTRATOR:JASMINE ZAMORAFACILITY TYPE:
737
ADDRESS:1605 VIOLA PLTELEPHONE:
(909) 671-4184
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY:3CENSUS: 3DATE:
05/11/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jai Seymour, Lead RBT TIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to client in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 05/11/2026 to deliver findings related to the above allegation. LPA met with Jai Seymour and explained the purpose of the visit.

The investigation included a review of the C1’s face sheet, C1's Individual Program Plan (IPP), Safety Net Plan, Individualized Behavioral Program and Special Incident Report (SIR). LPA conducted interviews with three (3) staff members (S1–S3) and client one (C1)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
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-20260501164858
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: PEOPLE'S CARE VIOLA
FACILITY NUMBER: 198602422
VISIT DATE: 05/11/2026
NARRATIVE
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Allegation: Staff did not provide adequate supervision to client in care.

It is alleged that staff failed to maintain line of sight supervision of C1 during a community outing, resulting in C1 leaving the area unsupervised after becoming anxious when staff was no longer visible. During staff interviews, staff admitted leaving C1 unattended while using a nearby restroom and did not notify C1 or arrange alternate supervision. Staff reported being away for approximately five (5) minutes and returned to find C1 missing. Additional staff confirmed C1 requires one to one supervision and staff are expected to maintain close supervision during outings. During C1’s interview, C1 reported staff did not inform C1 before leaving to use the restroom. C1 reported feeling scared and anxious after being unable to locate staff and believed staff had left the area. C1 reported leaving the park with their significant other and going to the significant other’s nearby home before contacting the facility to be picked up. C1 was not harmed during the incident. During record review, LPA reviewed C1’s Safety Net Plan signed by the facility, C1, and the Qualified Behavioral Management Professional (QBMP), C1’s and the Special Incident Report (SIR) regarding the incident dated 04/02/2026. The Safety Net Plan stated staff are required to maintain continuous line of sight supervision of C1 at all times and remain within approximately eight (8) feet of C1 unless otherwise clinically adjusted by the behavior consultant. The plan also included established community safety procedures.

Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260501164858
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: PEOPLE'S CARE VIOLA
FACILITY NUMBER: 198602422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2026
Section Cited
CCR
80078(a)
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(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 shall provide staff training regarding supervision requirements and community safety procedures. A written plan by POC due date to ensure compliance and Proof of Training (currivulum and sign in sheet) shall be submitted to CCL by the 05/25/26 due date.
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Based on interviews and record review, the facility did not comply with providing adequate supervision for C1 during a community outing, which poses/posed an immediate 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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3