198602544-10-5-2023-28-AS-DSIS-CWZS5W-20231027133500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602544
Report Date: 10/05/2023
Date Signed: 10/05/2023 04:00:27 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
07/05/2022 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220705163858

FACILITY NAME:	PEOPLE'S CARE FERRERO		FACILITY NUMBER:	198602544
ADMINISTRATOR:	AGAIOTUPU POUESI		FACILITY TYPE:	735
ADDRESS:	431 FERRERO LN		TELEPHONE:	(909) 287-3557
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY:	4	CENSUS: 3	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Angela Williams - Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff caused injury to resident's hand.

INVESTIGATION FINDINGS:

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***This report superseads report dated 09-08-23. The reason for superseading is to include missing information on the deficiency box of the original 9099D. In addition, citation 80072(a)(3) issued on 9-8-23 is being changed and corrected to 85102(a)(5). As a result of this regulation change, the immediate civil penalty of $1,000 also issued on 9/8/23 is being corrected to $500. The substantiated findings remain the same.***

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Angela Williams - Administrator and explained the purpose of the visit.

Investigation consisted of the following: During the initial visit conducted on 07/06/22, LPAs Long & Calderon conducted a health and safety check. LPAs toured the facility and observed food supply. No immediate health and/or safety concerns were observed.
(Continued on 9099C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220705163858

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 FERRERO	FACILITY NUMBER: 198602544
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/06/2023 Section Cited CCR 85102(a)(5)	1 2 3 4 5 6 7	(a) The following emergency interventions shall not be used on a client: (5) Pain, induced to control behavior or limit movement, including but not limited to arm twisting, finger bending, joint extensions and headlocks; This requirement is not met as evidence by	1 2 3 4 5 6 7	administrator to ensure that staff is properly conducting CPI holds to avoid injuy to clients in care.Administrator to submit written plan indicating how facility will meet this regulation. In addition, facility will retrain all staff in CPI within the next 2 weeks and submit list of staff members who participated in the training.
	8 9 10 11 12 13 14	based on interviews and record review it was determined that S1 and S2 caused a “spiral fracture of the right 1st metacarpal bone” to R1 during a CPI hold. This poses an immediate health, safety and/or personal rights risk to the clients in care.	8 9 10 11 12 13 14	POC cleared during visit
	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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220705163858

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 FERRERO	FACILITY NUMBER: 198602544
	VISIT DATE: 10/05/2023

NARRATIVE

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Investigation revealed the following:
In regards to the allegation “staff caused injury to resident’s hand”.
It is alleged that Resident #1 (R1) had been taken via ambulance to the Hospital due to swallowing some screws. While at the Hospital, R1 also alleged that a facility staff member had tried to break their hand on 07/01/22. This allegation was investigated by Investigator Miles with the Investigations Branch. Victim, witnesses, and staff member interviews were conducted.

On 07/01/22 Staff #1 (S1) and Staff #2 (S2), performed two Crisis Prevention Interventions (CPI) on R1. Interviews conducted revealed that R1 complained about pain to his hand, however R1 was never transported to the hospital. S1 and S2 were also aware of R1’s pain to his hand, however, did not seek medical attention for R1. On 07/04/22, 3 days after the CPI’s were performed, R1 was transported to the Hospital for evaluation. Hospital took X-Rays and discovered a “spiral fracture of the right 1st metacarpal bone”.

An immediate $500 Civil Penalty is being issued during today’s visit for causing injury to a client in care.

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(A) and may be assessed at a later date.

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.

Exit interview held and a copy of this report was provided along with appeal rights to Administrator Angela Williams.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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