198602619-9-2-2021-11-AS-JHAD-C7BVV9-20210929164556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602619
Report Date: 09/02/2021
Date Signed: 09/02/2021 10:29:54 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210813145045

FACILITY NAME:	ACOSTA FAMILY HOME III		FACILITY NUMBER:	198602619
ADMINISTRATOR:	ACOSTA, ASHLEY		FACILITY TYPE:	735
ADDRESS:	875 S ARANBE AVE		TELEPHONE:	(310) 554-4824
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY:	6	CENSUS: 2	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	04:06 PM
MET WITH:			TIME COMPLETED:	04:07 PM

ALLEGATION(S):

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Due to lack of supervision client wandered away
Staff failed to keep the facility clean
Staff isolated client

INVESTIGATION FINDINGS:

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On 9/2/21 at Licensing Program Analyst (LPA) Martessa Brown a subsequent visit in order to render investigation findings for the above allegations. LPA met with Ashley Acosta, the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 8/17/21, Licensing Program Analyst (LPA) Martessa Brown initiated the 10-Day visit and met with Ashley Acosta, the facility administrator. LPA conducted a Health and safety check. LPA toured the facility physical plant. Clients were not at the facility due to being at the day program. LPA reviewed staff #1-2 records, clients #1-2 records, staff #1-2 records and conducted interview with the administrator regarding the above allegation.

The investigation revealed the following:

LIC9099 is on the next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210813145045

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ACOSTA FAMILY HOME III	FACILITY NUMBER: 198602619
	VISIT DATE: 09/02/2021

NARRATIVE

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Regarding allegation: Due to lack of supervision client wandered away

On 8/16/21 LPA interviewed the reporting party regarding the above allegation. She stated C1 was at a another in 2016. and had wander away from the facility and was taken to jail She stated administrator did not report the incident. On 8/17/21 -9/2/21 LPA interviewed the Administrator and staff S1-S2 regarding the above allegation. Administrator stated C1 was with client when he wander away and not at her facility. Staff 1-2 stated they were not present during the incident.

Regarding allegation: Staff failed to keep the facility clean

On 8/16/21 LPA interviewed the reporting party regarding the above allegation. She stated C1 and C2’s bedrooms were not clean due to clients using the restroom on the floor and would desiccated. She stated staff did not clean the rooms. On 8/17/21 -9/2/21 LPA interviewed the Administrator and staff S1-S2 regarding the above allegation. Administrator and staff stated C1 did use the restroom floor and they would clean rooms. Administrator stated behaviorist was contact regarding incidents.

Regarding allegation Staff isolated client

On 8/16/21 LPA interviewed the reporting party regarding the above allegation. She stated C1 and C2’s was isolated in their rooms when they came from the hospital. On 8/17/21 -9/2/21 LPA interviewed the Administrator and staff S1-S2 regarding the above allegation. Administrator staff were in quarantine due to pending covid-19 results. S1 stated that the day program had a positive staff and C1 was around the staff and was awaiting pending results.

Although the allegations are valid or may have happened there is insufficient evidence to support the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and a copy of this report was provided Ashley Acosta, the Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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