198602619-3-17-2026-11-AS-JHAD-DSWRGB-20260407130029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602619
Report Date: 03/17/2026
Date Signed: 03/17/2026 02:56:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2026 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260309125823

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: 3	DATE:	03/17/2026
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Jonathan Stump		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not adequately supervise client in care resulting in client sustaining injuries.
Staff failed to provide adequate medical attention for client.

INVESTIGATION FINDINGS:

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On 3/17/26, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Jonathan Stump, Direct Support Professional. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and clients, and deliver findings for the allegations mentioned above.

The investigation consisted of the following: The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S3) and clients (C1-C2). The department received the following documents: ID/Emergency Information (Dated: 01/16/21,12/15/21), Preplacement Appraisal Information (Dated: 03/26/21), Individual Program Plan (Dated: 07/25/24), Physician’s Report (Dated: 01/20/26), Acosta Home First Aid Follow Up (Dated: 03/12/26), Special Incident Report (Dated: 03/12/2026), Face Sheet (Dated: 12/15/21), and Nonviolent Crisis Intervention Staff Training (Dated: 07/22/25-07/22/27) from the facility.

Report Continued On LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

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-20260309125823

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY HOME III	FACILITY NUMBER: 198602619
	VISIT DATE: 03/17/2026

NARRATIVE

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The investigation revealed the following: Allegation #1- Staff did not adequately supervise client in care resulting in client sustaining injuries.

The details of the complaint alleged that the facility’s client had bruises and open wounds on their back and did not notify anyone that they had these injuries. On 3/17/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and clients (C1-C2) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not adequately supervise client in care resulting in client sustaining injuries. All staff stated that the client is never left unattended at the facility. Staff stated that the client has self-injurious behaviors and is known to injure themselves as well disruptive social behavior and a tendency to destroy property. They also state that they do not believe that any staff were involved and caused the injuries to the client.

The department interviewed clients (C1-C2) about the allegations and 1 out of 2 clients denied having any injuries. While one client, due to cognitive difficulties, was not able to participate in the interview fully. However, staff (S1) with permission from the client (C1) showed me the abrasions on their back, and the department observed that they are healing

The department reviewed the Individual Program Plan (Dated: 07/25/24), Physician’s Report (Dated: 01/20/26), and Special Incident Report (Dated: 03/12/2026) and observed that the client has a history of self-injurious behavior and that the facility reported the incident to the Regional Center and Community Care Licensing Division.

Based on interviews and records that were reviewed, there is insufficient evidence to support the allegation that because of Staff did not adequately supervise client in care resulting in client sustaining injuries. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #2- Staff failed to provide adequate medical attention for client.

The details of the complaint alleged that the licensee did not get medical attention for client who had bruises and open wounds on their back. On 3/17/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S3) and clients (C1-C2) regarding the allegation. 3 of 3 staff denied the allegation that Staff failed to provide adequate medical attention for client. All staff stated that they did provide the client with medical attention. They stated that they applied first aid and Neosporin to the abrasions on the clients back and documented it in the facility files.

The department interviewed clients (C1-C2) about the allegations and 1 out of 2 clients denied needing medical attention. While one client, due to cognitive difficulties, was not able to participate in the interview fully. However, staff (S1) with permission from the client (C1) showed me the abrasions on their back, and the department observed that they are healing.

The department reviewed the Special Incident Report (Dated: 03/12/2026), Acosta Home First Aid Follow Up (Dated: 03/12/26), and Nonviolent Crisis Intervention Staff Training (Dated: 07/22/25-07/22/27), and observed the facility documented medical treatment given, reported the incident, and has specific training for clients with challenging behavior issues.

Report Continued On LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260309125823

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY HOME III	FACILITY NUMBER: 198602619
	VISIT DATE: 03/17/2026

NARRATIVE

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Based on interviews and records that were reviewed, there is insufficient evidence to support the allegation that Staff failed to provide adequate medical attention for client. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were found and no citations were issued for this complaint investigation.

An exit interview was conducted with Jonathan Stump, Direct Support Professional, and a hard copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC9099 (FAS) - (06/04)

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