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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602422
Report Date: 11/24/2021
Date Signed: 11/24/2021 09:29:31 AM

Unsubstantiated


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
11/05/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211105131207
FACILITY NAME:PEOPLE'S CARE VIOLAFACILITY NUMBER:
198602422
ADMINISTRATOR:ADRIANNA HARBINFACILITY TYPE:
737
ADDRESS:1605 VIOLA PLTELEPHONE:
(909) 671-4184
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY:3CENSUS: 3DATE:
11/24/2021
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Chris Rodriguez, Lead StaffTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff engaged in a physical altercation with a client while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with lead staff member, Chris Rodriguez and explained the reason for the visit. The initial complaint visit was conducted on 11/10/21.

The investigation consisted of the following: During the initial visit, interviews were conducted with two staff. Client #1's (C1) file was reviewed, and the facility was toured. A copy of C1's Individual Program Plan (IPP) and staff schedule were obtained. After the initial visit, C1 was interviewed along with two additional staff members. During today's visit, two additional clients were interviewed.

The investigation revealed the following: It's alleged Staff #1 (S1) assaulted C1 after having a verbal altercation. C1 reported that on 11/4/21 he/her was trying to talk to S1 about another situation that occurred the day before. According to C1, S1 didn't want to talk about it and C1 became upset. Allegedly C1 got in S1's face and both started hitting each other. Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
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 2
Control Number 28-AS-20211105131207
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: 11/24/2021
NARRATIVE
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S1 confirmed he/she was working with C1 on 11/4/21 and was the assigned 1:1 staff for C1. S1 confirmed C1 became upset about a situation that occurred the day before. However, S1 denies hitting C1. S1 indicated C1 became upset and attacked S1 in the living room. S1 reported that he/she retreated and yelled for staff to help. Staff #2 (S2) reported that he/she was in the office and did not see or hear the alleged incident. S1 reported to S2 what had allegedly occurred.

The other two clients that live in the home were not present at the time of the incident. There were no other staff members present for the incident. The facility does not have any cameras. Administrator responded 30 minutes after the incident occurred and took pictures of S1's injuries. S1 had a scratch in the eye and minor swelling around the eye. C1 had three scratches on the shoulder. It is unclear if the scratches were there prior to the incident. S1 denies hitting or assaulting C1. There were no other witnesses to the incident. There is insufficient evidence to prove the alleged incident occurred.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2