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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602620
Report Date: 10/03/2023
Date Signed: 10/03/2023 04:16:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
09/26/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20230926102244
FACILITY NAME:LONG BEACH RESIDENTIALFACILITY NUMBER:
198602620
ADMINISTRATOR:CRYSTAL BARRIENTOSFACILITY TYPE:
735
ADDRESS:4201 EAST 10TH STREETTELEPHONE:
(562) 433-2455
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:49CENSUS: 39DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Anthony GriffinTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff hit resident in care.
INVESTIGATION FINDINGS:
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On 10/03/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit to initiate the investigation on the above-mentioned complaint allegation. LPA met with Administrator Assistant Anthony Griffin and the purpose of the visit was explained.

The investigation consisted of the following: During todays visit, LPA Richard conducted a tour of the facility, interviewed the Assistant Administrator staff (S2), and Staff S3) residents (R1-R6) and 1 witness. LPA also reviewed staff and residents records.

The investigation revealed the following: On 09/26/2023, resident R1 was hit by Staff S1 at lunch time in the dining room. S2 stated "He didnt see the fight. He heard the commotion and ran upstairs. When he got there, the fighting was over. He found out that R1 threw a cup of juice onto S1's face, and then S1 left the kitchen to confront R1. Then R1 tackels S1 that's how the fight starts".
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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 5
Control Number 11-AS-20230926102244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 10/03/2023
NARRATIVE
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Staff hit Resident in care.

LPA Richard interviewed resident 1 (R1) the victim of the physical abuse. R1 claims he knows karate, boxing. R1 couldn't really explain what happened that day. Interviews with (R2-R6) all reported they did witness the incident. The only information the (R1) could provide was that the fight with S1 did occur. LPA interviews S3, who also witnessed the physical altercation that day. Interviews with (R2-R6) and (S2-S3) all Interviews claim this accusation is accurate. LPA Interviewed the father of the victim Johnny Johnson (W1). He stated that he is happy his son is OK, no injury, and he is grateful that the facility let him know what was going on.

Based on the evidence gathered, interviews conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation "Staff hit resident in care. is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Assistant Administrator (S2). Anthony Griffin.





SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20230926102244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2023
Section Cited
CCR
80072(a)(3)
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 80072(a)(3) Residential facilities each client shall have personal rights which include but not limited. (3) To be free from corporal or unsual punishment, Infliction of pain, humiliation, intimidation, ridicule ,coercion, threat, mental abuse or physical abuse...
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The Administrator will have staff review the personal right section. All staff must sign off indicating they have read and understand this regulation. facility will develop plan to ensure residents are free from abuse from staff. faciltiy must submitted to LPA the POC 10/4/23 antonine.richard@dss.ca.gov
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Based on a review of records and interviews, the facility staff failed to ensure resident was free from being hit by staff while in care. This poses apotential health and safety risk to all residents 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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
09/26/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20230926102244

FACILITY NAME:LONG BEACH RESIDENTIALFACILITY NUMBER:
198602620
ADMINISTRATOR:CRYSTAL BARRIENTOSFACILITY TYPE:
735
ADDRESS:4201 EAST 10TH STREETTELEPHONE:
(562) 433-2455
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:49CENSUS: DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
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9
Staff engaged in a verbal altercation with resident in care.
INVESTIGATION FINDINGS:
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On 10/03/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit to initiate the investigation on the above-mentioned complaint allegation. LPA met with Administrator Assistant Anthony Griffin and the purpose of the visit was explained.

The investigation consisted of the following: During todays visit LPA Richard conducted a tour of the facility, interviewed the Assistant Administrator staff (S2), and Staff S3), residents (R1-R6). LPA also reviewed staff and residents records.

The investigation revealed the following: On 09/26/2023, staff engaged in verbal altercation with resident in care. S2 stated staff had never spoken to resident inappropriately. Staff (S2) stated they have never spoken to resident on a threatening or engaged in a verbally altercation with residents. S3 stated resident gets roddy sometimes but still they don't deserve to get verbally abused, she never witnessed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230926102244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 10/03/2023
NARRATIVE
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Staff engaged in a verbal altercation with resident in care.

LPA Richard interviewed resident 1 (R1) the victim of the physical abuse. R1 claims he knows karate, boxing. R1 couldn't really explain what happened that day. Interviews with (R2-R6) all reported they have not experienced or witness any staff engage in a verbal altercation with residents. The only information the (R1) was able to provide was that the fight with S1 did occur. Interviews with (R2-R6) and (S2-S3) all Interviews claim this accusation is inaccurate.

Based on the evidence gathered, interviews conducted and the records that were reviewed, the preponderance of evidence standard has not been met, therefore the above allegations "Staff engaged in a verbal altercation with resident in care is found to be UNSUBSTANTIATED.

An exit interview was conducted and a copy of the report was provided to the Assistant Administrator (S2). Anthony Griffin.


SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5