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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602585
Report Date: 05/11/2022
Date Signed: 05/11/2022 11:51:10 AM

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
05/04/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220504100050
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: 0DATE:
05/11/2022
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:LaTonya King-Administrator TIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Facility abandoned resident at the hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted the initial 10 day complaint investivation. LPA met with DSP Monica Martinez and explained the reason for today's visit. Shortly after, LaTonya King (Administrator) arrived and assisted with the visit.

The investigation consisted of the following: LPA interviewed two staff (S1 and S2) and administrator and reviewed Client #1 (C1) file and obtained C1's copy of face sheet, Indvidual Program Plan (IPP), adminsitrator notes, physician report, discharge summary (3/31/22), incident reports dated on 4/16/22, 4/21/22, 4/22/22, 4/26/22, 4/28/22 , psychiatirst letter dated on 4/27/22 and 3 days evication notice dated on 5/3/22.

(See LIC9099C 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: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
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-20220504100050
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: 05/11/2022
NARRATIVE
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 The investigation reveled of the following: "Facility abandoned resident at the facility." LPA interviewed administrator and reported that the facility/corporate office is not planning to take C1 back to the facility because C1 was having severely verbally aggressive behaviors and threatening behavior to staff. C1 had been cursing and threatening the staff daily and stated that he's going to hurt and kill the staff. All staff do not feel safe while C1 was in the facility. In addition, staff also found a bag of marijuana in C1's room. C1 was repeated using a white powder drug while inside the facility. Administrator and Staff reported they never got a call from the hospital regarding accept C1 back to the facility or not. The administrator also stated that the facility did file the 3 days eviction notice for C1 on May 3, 2022 and Community Care Licensing (CCL) has never approved the 3 days eviction notice which does not meet the eviction protocol. While LPA reviewed C1's file, LPA did not see the 30 days eviction notice for C1. The administrator also admitted that the facility never filed the 30 days eviction notice for C1. The facility only reported to C1's service coordinator that C1 needs a higher level of care.

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 Administrator LaTonya King.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220504100050
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: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2022
Section Cited
CCR
85068.5(b)(1)
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85068.5 Eviction Procedures (b) The licensee shall be permitted to evict a client by serving the client with a three-day written notice to quit ....following requirements have been met:(1) The licensing agency has granted prior written and/or documented telephone approval for the eviction.
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The facility will ensure the 3 days eviction notice needs to be granted prior written/documented telephone approval for the eviction by licensing agency. The facility will send LPA a plan how to avoid it happened in the future.
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The requirment was not met as evidenced by: the facility was given a 3 day eviction notice for Client#1 without Licensing agency granted approval.
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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: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3