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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602585
Report Date: 07/01/2022
Date Signed: 07/01/2022 01:29:36 PM

Unsubstantiated


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
11/23/2021 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211123160234
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:
07/01/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Samuel Ayansola (Direct Support Professional)TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident was left unsupervised by staff.
Staff spoke inappropriately to client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced subsequent complaint visit to the facility. Upon arrival, LPA met with Samuel Ayansola (Direct Support Professional) and explained the purpose of the visit.

During the initial complaint visit on 11/30/21, LPA obtained a copy of the Staff Schedule/Client Roster and Client#1's records (Physician's Report, Individual Program Plan, Psychological Evaluation) and interviewed Staff #1 at 12:30 pm in the dining area.

During today's visit, LPA obtained a copy of the Staff/Client rosters, interviewed Staff #2 and Staff #3 in the dining area and interviewed Clients #2 in their bedrooms.

Continue to LIC9099C....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
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 2
Control Number 28-AS-20211123160234
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: 07/01/2022
NARRATIVE
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In regards to the allegation: Resident was left unsupervised by staff. Interviews with 3 of 3 Staff indicate they have never left a Client unsupervised nor have they witnessed other Staff leave a Client unsupervised. Interview with 1 of 1 Client indicate that Clients have never been left unsupervised by Staff. Interview with Witness indicate that incident of Staff leaving Client unsupervised was fabricated.

In regards to the allegation: Staff spoke inappropriately to client. Interviews with 3 of 3 Staff indicate they have never spoken to a Client inappropriately nor have they witnessed other Staff speaking to a Client inappropriately. Interview with 1 of 1 Client indicate that Clients have never been spoken to inappropriately by Staff nor has Client witnessed Staff speaking to other Clients inappropriately.

Based on LPA's interviews, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and a copy of this report provided to Samuel Ayansola.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2