198602422-9-14-2023-28-AS-TVAO-CVPMJJ-20230915093914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602422
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:15:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/09/2022 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220309083248

FACILITY NAME:	PEOPLE'S CARE VIOLA		FACILITY NUMBER:	198602422
ADMINISTRATOR:	ADRIANNA HARBIN		FACILITY TYPE:	737
ADDRESS:	1605 VIOLA PL		TELEPHONE:	(909) 671-4184
CITY:	POMONA	STATE: CA	ZIP CODE:	91766
CAPACITY:	3	CENSUS: 3	DATE:	09/14/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jordan Henry		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Lack of supervision resulting in client ingesting a foreign object.
Staff not following client's Individualized Behavioral Support Plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Jordan Henry and discussed the purpose of today’s visit.

On 03/11/22, LPA Irra conducted the initial investigation and met with Adrianna Harbin (Facility Administrator). During this visit, LPA obtained a copy of the Client Roster, a copy of the Staff Roster (including contact information), interviewed Facility Administrator/S-1 and Staff # (S-2). LPA also reviewed C-1's file and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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-20220309083248

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEOPLE'S CARE VIOLA	FACILITY NUMBER: 198602422
	VISIT DATE: 09/14/2023

NARRATIVE

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During this investigation, LPA interviewed Staff #1 (S-1) through Staff #3 (S-3) and Staff #6 (S-6). LPA was unable to interview Staff #4 (S-4) and Staff #5 (S-5) as both no longer work at this facility. However, LPA obtained facility notes entered by S-4 and S-5 pertaining to these incidents. Additionally, San Gabriel Pomona Regional Center also conducted an investigation in regards to these incidents. LPA reviewed C-1’s file and obtained relevant documentation. LPA was unable to interview Client #1 (C-1) through Client #3 (C-3). C-1 and C-2 were at day program and C-3 is currently hospitalized.

Allegation: Lack of supervision resulting in client ingesting a foreign object. Interviews conducted and reviewed documentation revealed that on 01/18/22, C-1 ingested a remote TV battery and on 02/09/22, C-1 ingested a quarter both of which were confirmed by an x-ray examination. According to C-1’s behavioral support plan, C-1 has a “PICA-like behavior: inserting any item that is not meant to be consumed into mouth (may or may not swallow the object)”. Items may include, pieces of plastic, coins, batteries, leaves of a decorative shrubbery, ect.. Per documentation, C-1 requires supervision at all times. Due to lack of supervision, this resulted in C-1 ingesting foreign objects as noted above. Interviews conducted and reviewed documentation corroborates this allegation.

Allegation: Staff not following client's Individualized Behavioral Support Plan. C-1’s behavioral support plans address C-1’s “PICA-like behavior: inserting any item that is not meant to be consumed into mouth (may or may not swallow the object)”. Items may include, pieces of plastic, coins, batteries, leaves of a decorative shrubbery, ect.). C-1’s behavioral support plan provides staff with strategies on how to reduce behavior being addressed, teaching strategies, proactive procedures, reactive procedures and supervision policies and procedures. C-1’s supervision policies and procedures include “staff will not exceed more than eight feet away from C-1 at any time”. Per C-1’s behavioral plan, “staff will always maintain line of sight with C-1”. Interviews conducted and reviewed documentation corroborates this allegation as C-1 ingested foreign items on (2) separate occasions which are noted above.

Based on LPA’s interviews and records review, the preponderance of evidence standard has been met; therefore, the allegations noted above are found to be SUBSTANTIATED.

Deficiency observed and cited per California Code of Regulation Title 22 Division 6. Refer to LIC9099D.
Exit interview held, copy of report and Appeal Rights provided to Marc Marquez

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220309083248

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 09/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/14/2023 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This standard is not met as evidence by: Interviews conducted and reviewed documentation revealed that on 01/18/22, C-1 ingested a remote TV battery	1 2 3 4 5 6 7	Facility Administration to submit proof of staff training pertaining to C-1’s behavioral support plans. Cleared at this of visit as LPA was provided which proof of training.
	8 9 10 11 12 13 14	and on 02/09/22, C-1 ingested a quarter both of which were confirmed by an x-ray examination. C-1’s supervision policies and procedures include “staff will not exceed more than eight feet away from C-1 at any time”. Per C-1’s behavioral plan, “staff will always maintain line of sight with C-1”	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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