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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602585
Report Date: 12/13/2022
Date Signed: 12/13/2022 04:47:50 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
12/06/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221206155906
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: 3DATE:
12/13/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:LaTonya King TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff spoke inappropriately towards a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an initial complaint visit at the facility to investigation the above allegation. LPA met with DSP Oyinade Ajiboye (Esther) and explained the reason of the visit. Shortly after, the administrator LaTonya King came and assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed three clients (C1-C3) , administrator and one staff via phone and two staff in the facility.

The investigation revealed of the following: In regard to the allegation "Staff spoke inappropriately towards a client while in care" LPA interviewed three clients and two out of three clients stated that the staff did speak inappropriately to them. LPA interviewed staff and administrator, staff and administrator both admitted that the staff did call client an inappropriate name in return as staff tried to redirect client while doing laundry but client got upset and yelled at the staff by calling staff different type of offensive names.
(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
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 3
Control Number 28-AS-20221206155906
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: CENTER FOR BEHAVIORAL CHANGE #5
FACILITY NUMBER: 198602585
VISIT DATE: 12/13/2022
NARRATIVE
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Based on LPA’s interviews conducted with staff and clients, 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 Administrator LaTonya King.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221206155906
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: CENTER FOR BEHAVIORAL CHANGE #5
FACILITY NUMBER: 198602585
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2022
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a) Except for ....... each client shall have personal rights.. following (3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions
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The administrator will ensure each client shall have personal right and administrator will retrain all staff about personal right and send the in service training log to LPA by POC due date.
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The requirement was not met as evidenced by LPA's interviews, 2 out of 3 clients stated that Staff spoke inappropriate and administrato and staff both admitted to call client inappropriate name in return which caused a potential risck to 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3