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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602544
Report Date: 08/23/2022
Date Signed: 08/23/2022 04:14:59 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
08/15/2022 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20220815111123
FACILITY NAME:PEOPLE'S CARE FERREROFACILITY NUMBER:
198602544
ADMINISTRATOR:AARON EATONFACILITY TYPE:
735
ADDRESS:431 FERRERO LNTELEPHONE:
(909) 287-3557
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:4CENSUS: 3DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Eden TupuolaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not meet reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an initial 10 days complaint investigation for the above allegation. LPA met with house lead George Aliimatafitafi and explained the purpose of the visit. Shortly after, the administrator Aaron Eaton arrived and assisted with the visit.

The investigation consisted of the following: LPA interviewed administrator, three staff (S1-S3) and three clients (C1-C3). LPA also obtained the documents including C4's incident report dated on 6/21/22, 7/1/22 and 7/5/22 and C1's inicdent report dated on 7/23/22 , copy of staff CPI card and recent staff CPI training log and topic.

The investigation revealed of the following: Allegation: "Staff did not meet reporting requirements" LPA interviewed the administrator and stated that that he just started working at the facility since June 2022 and was not aware of that needed to be reported or submitted an incident report to Community Care Licensing (CCL) until two to three weeks ago. (See LIC 9099 for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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 4
Control Number 28-AS-20220815111123
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 FERRERO
FACILITY NUMBER: 198602544
VISIT DATE: 08/23/2022
NARRATIVE
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 In addition, LPA also reviewed the CCL facility incident report log and LPA did not receive any incident report from the facility in the month of June and July, 2022.

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) cited on the attached 9099 D.

Exit interview conducted and the copy of the report and appeal right was provided to House Lead Eden Tupuola
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20220815111123
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 FERRERO
FACILITY NUMBER: 198602544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited
CCR
85161(b)
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85161 Emergency Intervention Documentation and Reporting Requirements (b) Each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day.
The requirement is not met as evidenced by
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Administrator will ensure each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day and Administrator will retrain his staff about reporting requirement and send the staff training log to LPA by POC due date
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LPA's observation and record review, LPA did not receive any incident report about clients got restrained between June and July, 2022 and administrator also admitted that he was not aware of that he needed to be reported which pose an potenital risk to the 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: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4