198602875-12-15-2023-28-AS-RORN-CZ4P2H-20240102095558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602875
Report Date: 11/28/2023
Date Signed: 12/15/2023 01:22:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231121103815

FACILITY NAME:	CASA BARBARA		FACILITY NUMBER:	198602875
ADMINISTRATOR:	HENRY A LARA		FACILITY TYPE:	735
ADDRESS:	3453 LIBERTY BOULEVARD		TELEPHONE:	(562) 682-9667
CITY:	SOUTH GATE	STATE: CA	ZIP CODE:	90280
CAPACITY:	4	CENSUS: 4	DATE:	11/28/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Henry Lara - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not prevent resident from punching another resident.

INVESTIGATION FINDINGS:

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****This is an amended version of the original report created on 11/28/2023. This report is being amended to remove confidential information. No other changes have been made to the report. Investigation findings remain the same. ****

Licensing Program Analyst (LPA) Bennette Pena conducted a complaint investigation for the above allegation. No one answered the door upon arrival. LPA called Henry Lara, Administrator to explain the reason for the unannounced visit. Henry Lara, Administrator arrived at 11:15am and assisted LPA with the investigation.

LPA obtained copies of the Staff and Client Rosters, toured the facility, Staff In-service training for Zero Tolerance Policy (04/29/2023) and reviewed files for Client #1 (C1) - Client #2 (C2) such as: Admission Agreement, Face Sheet/Identification and Emergency Information, SCLARC Annual Individual Program Plan (IPP) (C1) dated 10/13/2022 and10/30/2022, (C2) dated 10/18/2022, Behaviorist Quarterly Report (Independent Consulting Services C1 dated 04/22/2023 and C2 dated 06/30/2023), (C1) Physician's Report (4/12/2023 & 5/27/2023) & (C2) (05/10/2023 & 6/08/2023), and Incident reports (SIRs) involving C1-C2 dated 01/22/2023, 02/11/2023, and 11/21/2023. LPA also interviewed Staff #1 (S1) and telephonically interviewed Staff #2 (S2) - Staff #4 (S4) and Client #1 (C1) and Client #2 (C2). *****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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 28-AS-20231121103815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA BARBARA	FACILITY NUMBER: 198602875
	VISIT DATE: 11/28/2023

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: “Staff did not prevent resident from punching another resident”, it is alleged that a client (C1) punched another client (C2) in the face but did not have any injuries. It is also alleged that there have been issues between these 2 clients before. The incident occurred in C2’s room in the facility. Staff interviewed denied the allegation and stated that they always monitor clients closely and that they have training on zero tolerance policy. Staff members who witnessed the incident stated that for no reason or provocation, C1 hit C2 on the back, not on the face and they intervened immediately. Staff members re-directed them and separated C1 and C2. Staff members used verbal redirecting, giving both clients space, and used coping skills to manage C1’s behavior. Staff members also stated that they notified the facility management immediately and contacted the Law Enforcement who arrived to investigate. S1 stated that right after the incident, they conducted a body check on C2 who did not suffer any injury. Staff members also offered to take C2 to the Emergency room to be checked, but C2 refused. S1 also stated that C1 and C2 get along well most of the time, like best friends and they help each other. Clients interviewed stated that clients get along well in the facility. C1-C2 stated that staff are caring, they monitor them at all times and will quickly intervene if a situation arise to protect their health and safety. LPA reviewed the incident reports (SIRs dated 01/22/2023, 02/11/2023 and 11/21/2023) indicating that the staff redirected C1 to different activity and separated C1-C2 immediately when C1 displayed verbal or physical aggression towards C2. Therefore there was insufficient evidence to corroborate this allegation.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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.

Exit interview held, and a copy of this report was provided to Henry Lara, Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

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