198602576-11-2-2023-28-AS-TVAO-CXKNFP-20231114092548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602576
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:31:32 PM

Unsubstantiated

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
09/08/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230908081701

FACILITY NAME:	VICTORIOUS RESIDENTIAL HOME II		FACILITY NUMBER:	198602576
ADMINISTRATOR:	ORUNESAJO, AKINWALE VICTOR		FACILITY TYPE:	735
ADDRESS:	202 CALLE DESCANSO		TELEPHONE:	(818) 448-3012
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY:	5	CENSUS: 4	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	12:11 PM
MET WITH:	Victor Orunesajo, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit for the allegation listed above. LPA met with Administrator, Victor Orunesajo, and explained the reason for the visit.

On 9/12/23, LPA Chan conducted the initial visit and interviews were held. LPA also requested documents. On 11/2/23, LPA interviewed 4 additional staff, the San Gabriel/Pomona Regional Center Service Coordinator, and attempted to interview Client #1 (C-1).

The investigation revealed the following:
Allegation – Client sustained unexplained bruising while in care. LPA interviewed the administrator and staff regarding the bruise that was discovered on Client #1’s (C-1) left buttock. Staff reported they did not observe any bruises on C-1 in prior days or day of when C-1 was picked up by the mother. Staff stated they normally perform body checks when clients are being showered and would report right away if they observe any bruises/injuries on clients.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 2

Control Number 28-AS-20230908081701

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: VICTORIOUS RESIDENTIAL HOME II	FACILITY NUMBER: 198602576
	VISIT DATE: 11/02/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

They are constantly monitoring clients and redirecting clients when they engage in their behaviors. Administrator stated he reported it to appropriate agencies when the bruise was discovered. He also stated that a welfare check was conducted by the Walnut Sheriff’s Department on 9/7/23. LPA received a copy of the report number and the incident report that was faxed over to Licensing.

LPA obtained and reviewed copies of the regional center’s annual progress report and quarterly progress reports. The reports show that C-1 has self-injurious behaviors and behavior of lying on the floor and rocking. Staff interviewed described that C-1 does not sit down on the floor slowly, but rather, drops rapidly in a sitting position. C-1 would exhibit the same behaviors whether in a good mood or not. LPA also interviewed the C-1’s Regional Center Service Coordinator and confirmed C-1 has the tendency to drop to the ground, roll/rock around, or hit/swing head.

Based on information gathered, the bruise observed on C-1 did not appear to be caused by the staff or staff negligence. 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.

An exit interview was conducted with the administrator. A copy of this report along with the appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2