198602625-4-14-2021-11-AS-MCAA-C28R9N-20210419124946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602625
Report Date: 03/26/2021
Date Signed: 04/14/2021 03:29:46 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
08/06/2020 and conducted by Evaluator Jade Jordan

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200806171456

FACILITY NAME:	SHERMAN RESIDENTIAL CARE		FACILITY NUMBER:	198602625
ADMINISTRATOR:	ROBINSON, TANIKA T		FACILITY TYPE:	735
ADDRESS:	5322 THIRD AVE		TELEPHONE:	(323) 443-6633
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90043
CAPACITY:	4	CENSUS: 3	DATE:	03/26/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Alek Torosyan		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

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Lack of supervision resulting in resident causing injury to another resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst LPA/Jade Jordan initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with the facility administrator.

Regarding the allegation: “Lack of supervision resulting in resident causing injury to another resident in care.”
Based on record review of C2’s Individual Program Plan (IPP), it is not known of c2 to cause physical injury to another. C1 has no history documented in IPP of Aggressive behavior. According to interview C1, said that they were friends, and often play fought. Staff interviews also corroborated that C1 and C2 would often play fight, and or wrestle in the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021

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-20200806171456

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: SHERMAN RESIDENTIAL CARE	FACILITY NUMBER: 198602625
	VISIT DATE: 03/26/2021

NARRATIVE

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According to IPP reports, C1 can function independently without supervision in the community. C2 can function independently in least restrictive environment. The incident took place within the perimeters of the facility, outdoors. According to interviews a staff was onsite, but inside the facility. Interviews confirm, staff did check on clients outside, but that staff did not witness the altercation which lead to the intentional physical injury from C2, to C1.

Based on interviews and record review the LPA finds that although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No citations were issued during this visit.

An exit interview was conducted, and a copy of this report was given. Advised to sign and return back to
LPA at Jade.Jordan@dss.ca.gov, or fax 323-981-1781.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

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