198602856-12-12-2025-11-AS-SCIS-DPF3DL-20251216170944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602856
Report Date: 11/05/2025
Date Signed: 12/12/2025 01:42:56 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, 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
06/26/2025 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20250626162940

FACILITY NAME:	EASTERSEALS SOUTHERN CALIFORNIA-KALLIN RESIDENCE		FACILITY NUMBER:	198602856
ADMINISTRATOR:	DRUMMOND, MARIA		FACILITY TYPE:	735
ADDRESS:	824 KALLIN AVE		TELEPHONE:	(818) 512-2494
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	3	CENSUS: 3	DATE:	11/05/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Alex Hernandez Ramirez		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Client sustained unexplained injury while in care.

INVESTIGATION FINDINGS:

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On 11/05/2025, the California Department of Social Services Community Care Licensing Division (CDSS/CCLD) Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced subsequent visit to gather information regarding the above allegation. LPA Bunker met with Alex Hernandez Ramirez, the Administrator, and explained the purpose of the visit.

The investigation consisted of the following: On 07/02/2025 and 11/05/2025, LPA Bunker reviewed and obtained copies of Client 1's records, Client Roster (Dated 08/17/2024), Personnel Report (Dated 04/21/2025), Special Incident Report (SIR), S1 stated that the SIR was reported to CCLD via telephone on 06/26/2025, Proof of Submission was provided through a confirmation email, verifying that the SIR was submitted on (Dated 06/27/2025), Admission Agreement (Dated 03/14/2019), Identification and Emergency Information (Dated 05/07/2025), Physician’s Report (Dated 01/07/2025), Appraisal & Needs and Services Plan (Dated 10/11/2021), Functional Capability Assessment (Dated 02/15/2018),
See continued LIC9099-C page 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

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 4

Control Number 11-AS-20250626162940

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: EASTERSEALS SOUTHERN CALIFORNIA-KALLIN RESIDENCE	FACILITY NUMBER: 198602856
	VISIT DATE: 11/05/2025

NARRATIVE

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Continued LIC9099-C page 3.

S1, S2, and S4 reported that at approximately 3:00 a.m., a staff member heard a noise coming from the client’s bedroom. Upon entering the room, the staff member found the client on the floor. The overnight staff assisted the client back to bed and noticed the client’s nose was bleeding. They cleaned the nose, and the client returned to sleep. The overnight staff were unable to explain how the client sustained these injuries while under their care.

When the morning staff members observed the client, they noted a black eye on the right side of the client's face and a bleeding nose. Hospital records from Los Alamitos ER (dated 06/26/2025) and Providence Mission Hospital (dated 06/27/2025) documented the injuries, including a closed fracture of the right zygomatic arch.

On 06/27/2025, staff submitted the Special Incident Report (SIR) in accordance with Title 22 Regulations. All three staff members confirmed that they received re-training on Responsibility for Providing Care and Supervision, Reporting Requirements, and relevant policies, procedures, and regulations. Three of the staff members admitted to the allegation.

On 07/02/2025, from 11:00 a.m. to 3:30 p.m., the Department attempted to interview three clients #1-#3 (C1-C3); however, they were non-verbal and unable to respond to any questions.

On 07/02/2025 at 4:00 p.m., the Department conducted an interview with witness #1 (W1). W1 stated that they attempted to interview the client, but the client was non-verbal and unable to answer any questions.
W1 reported that they interviewed staff members, who indicated that the overnight staff heard a noise coming from the client’s bedroom. Upon entering the room, a staff member found the client on the floor, appearing to have fallen out of bed. The overnight staff assisted the client back to bed and noticed that the client’s nose was bleeding. They cleaned the nose, and the client returned to sleep. When the morning staff observed the client, they noted a black eye on the right side of the client’s face and a bleeding nose. The client was subsequently transported to the emergency room by staff for medical evaluation. W1 confirmed that the incident was reported to Harbor Regional Center on 06/26/2025.

See continued LIC9099-C page 4.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20250626162940

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: EASTERSEALS SOUTHERN CALIFORNIA-KALLIN RESIDENCE	FACILITY NUMBER: 198602856
	VISIT DATE: 11/05/2025

NARRATIVE

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Continued LIC9099-C page 2.

Preplacement Appraisal Information (Dated 02/15/2019), Consent Form (Dated 01/23/2024), Skin Assessment Report (dated 06/26/2025), Los Alamitos Emergency Room (Dated 06/26/2025), and Discharged Records, Providence Mission Hospital (Dated 06/27/2025).

Interviews were conducted with staff members #1, #2, and #4 (S1, S2, and S4). Staff #3 (S3) was not available for the interview. LPA also attempted to interview clients #1–#3 (C1–C3); however, they were non‑verbal and unable to respond to questions. An interview was conducted with witness #1 (W1).

On 11/05/2025 at 12:44 p.m., S2 Administrator Alex Hernandez Ramirez and LPA Bunker toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit.

Allegation: Client sustained an unexplained injury while in care.
It was alleged that the client sustained an unexplained injury while under staff supervision. LPA Bunker reviewed the client's Record of Health Care Visit dated 06/26/2025, and the Skin Assessment Report shows that staff conducted a complete body check on 06/26/2025 prior to the client being transported to the Los Alamitos Emergency Room (ER). The ER doctor ordered a CT scan of the client's head, and a nurse performed a full body check, noting a small bruise on the client’s right elbow. The CT scan revealed fractures to the right orbit of the eye. On 06/27/2025, the client was discharged from Los Alamitos ER and transferred at 5:04 a.m. to Providence Mission Hospital for further evaluation by an orthopedic facial specialist. It was determined in the pre-medical report dated 06/27/2025 that the client had a closed fracture of the right zygomatic arch. The client was discharged later that same day and returned to the facility with instructions to follow up in two weeks with the client's primary care physician.

On 07/02/2025 (2:15 p.m. to 4:00 p.m.) and 11/05/2025 (11:00 a.m. to 4:30 p.m.), the Department conducted interviews with staff members #1, #2, and #4 (S1, S2, and S4). All three staff members confirmed that the incident was reported to the appropriate agencies in a timely manner. However, they indicated that the overnight staff did not inform the morning staff of the incident until 1 hour and 45 minutes after it occurred. See continued LIC9099-C page 3.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20250626162940

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: EASTERSEALS SOUTHERN CALIFORNIA-KALLIN RESIDENCE	FACILITY NUMBER: 198602856
	VISIT DATE: 11/05/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Continued LIC9099-C page 4. There were no deficiencies cited. Complaint Investigation Report LIC 9099 and LIC9099-C were provided to Alex Hernandez Ramirez, the Administrator. An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4