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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602585
Report Date: 09/27/2022
Date Signed: 09/27/2022 04:19:23 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
09/21/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220921100647
FACILITY NAME:CENTER FOR BEHAVIORAL CHANGE #5FACILITY NUMBER:
198602585
ADMINISTRATOR:LATONYA KINGFACILITY TYPE:
735
ADDRESS:2111 EAST GARVEY AVE NORTHTELEPHONE:
(626) 502-1424
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 4DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Oyinade OkokoTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff failed to dispense medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an initial 10 days complaint investigation to investigation the above allegation. LPA met with DSP Monica Martinez and explained the purpose of the visit.

The investigation consisted of the following: On today's date, LPA interviewed three clients (C1-C3) and three staff (S1-S3) in the facility and administrator and C4 via telephone. LPA also reviewed C1-C4 medication and Medication Administration Record (MARs)

The investigation revealed of the following: In regard to the allegation "Facility staff failed to dispense medication as prescribed. " LPA interviewed clients and reported they all get their medication on time and staff are on top of their medication. LPA reviewed C1-C4 medication and the MARs, and observed C1's medication - Clonazepam 0.5mg and Fluconazole 200mg were missing. There's no discontinued order or no physician order in the facility.
(See LIC 9099C 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: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
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 5
Control Number 28-AS-20220921100647
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: CENTER FOR BEHAVIORAL CHANGE #5
FACILITY NUMBER: 198602585
VISIT DATE: 09/27/2022
NARRATIVE
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For C2, Biktarvy 50-200-25mg, Magnesium Oxide 400mg, Melatonin 5mg, Oyster Shell+ D 500/200, Progesterone 100mg and Vitamin C 500mg were missing and there's no discontinued order or physician order was noted. For C3, Trulicity 0.75mg/0,5ML were missing in the facility and staff reported its been discontinued and there's no discontinued order in the facility.

Based on LPA’s interviews and records 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.

An exit interview was conducted. A copy of this report and the appeal Right were provided to the DSP Oyinade Okoko.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220921100647
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: CENTER FOR BEHAVIORAL CHANGE #5
FACILITY NUMBER: 198602585
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited
CCR
80075(b)(5)(B)
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80075 Health Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5)If the client's physician has stated in writing that the client is unable to.... providing all of the following requirements are met:
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The administrator will ensure once the medication ordered by the physician the medication is given according to the physician direction. The administrator will immediately contacted with the doctor and refill the medication or obtain the discontinued notice from medication and
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(B)Once ordered by the physician the medication is given according to the physician's directions. The requirement is not met as evidenced by: C1's medication - Clonazepam 0.5mg and Fluconazole 200mg were missing. For C2, Biktarvy 50-200-25mg, Magnesium Oxide 400mg, Melatonin 5mg, Oyster Shell+ D 500/200, Progesterone 100mg and Vitamin C 500mg were missing. For C3, Trulicity 0.75mg/0,5ML were missing in the facility
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the administrator will retrain the staff on medication and send the staff training log to LPA by 10/4/22.
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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: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/21/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220921100647

FACILITY NAME:CENTER FOR BEHAVIORAL CHANGE #5FACILITY NUMBER:
198602585
ADMINISTRATOR:LATONYA KINGFACILITY TYPE:
735
ADDRESS:2111 EAST GARVEY AVE NORTHTELEPHONE:
(626) 502-1424
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 4DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Esther Okoko TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are not serving adequate food portions to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an initial 10 days complaint investigation to investigation the above allegation. LPA met with DSP Monica Martinez and explained the purpose of the visit.

The investigation consisted of the following: On today's date, LPA interviewed three clients (C1-C3) and three staff (S1-S3) in the facility and administrator and C4 via telephone. LPA also reviewed C1-C4 medication and Medication Administration Record (MARs)

The investigation reveled of the following: In regards to the allegation "Staff are not serving adequate food portions to residents." LPA interviewed four clients and three out of four reported the facility staff provide adequate food portion and they were always able to get second if they needed. They never got hungry in the facility. LPA interviewed staff and staff reported no clients ever complained to staff that food was not sufficient or they do not have enough portion of food.
(See LIC 9099 for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220921100647
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: CENTER FOR BEHAVIORAL CHANGE #5
FACILITY NUMBER: 198602585
VISIT DATE: 09/27/2022
NARRATIVE
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LPA also observed the two days perishable food in the kitchen refrigerator and the freezer in the garage. LPA observed there's variety of food/meat in the refrigerator and freezer. Administrator also reported she and the staff would work on the weekly menu with the clients and they would do grocery shopping according to what clients like.

Based on LPA's interviews conducted, recorded review and observation, investigation revealed: Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, and a copy of report and appeal right was provided to DSP Oyinade Okoko.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5