198602883-2-7-2023-11-AS-SCIS-CRWPS7-20230517113349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602883
Report Date: 02/07/2023
Date Signed: 02/07/2023 07:19:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
02/01/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20230201112909

FACILITY NAME:	SANDRA'S HOUSE LLC #3		FACILITY NUMBER:	198602883
ADMINISTRATOR:	BENSON, SANDRA		FACILITY TYPE:	735
ADDRESS:	1908 STEVELY AVE		TELEPHONE:	(562) 843-8522
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	4	CENSUS: 4	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Sandra Benson and April Gorman		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff do not prevent an adult from causing harm to clients while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, February 07, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensee Sandra Benson and Administrator April Gorman. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-2 (S1-S2), client 1-2 (C1-C2), C3 had difficulty understanding the questions and was unable to hold a conversation, and C4 is non-verbal. LPA Bunker asked questions relevant to the nature of the complaint. We toured the entire facility inside and outside grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. S1-S2 and C1-C2 stated the facility staff is not causing any harm to the clients in care.
See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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 11-AS-20230201112909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANDRA'S HOUSE LLC #3	FACILITY NUMBER: 198602883
	VISIT DATE: 02/07/2023

NARRATIVE

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Continued LIC9099-C page 2

LPA Bunker observed the client's records and requested copies of supporting documents.

Allegation: Staff do not prevent an adult from causing harm to clients while in care
S1-S2 and C1-C2 stated staff did prevent an adult from causing harm to clients while in care. The facility staff is the person who self-reported this complaint allegation regarding the action of someone outside the facility causing harm to the clients in placement prior to the complaint being filed.

The Investigation revealed the following: Staff 1-2 (S1-S2) and client 1-2 (C1-C2) interviewed stated staff did prevent an adult from causing harm to clients while in care. S1-S2 and C1-C2 stated the action of someone outside of the facility came to the facility and was verbally aggressive, yelling, screaming, threatening, and arguing with C2, making the facility staff and clients afraid, and uncomfortable in their home and environment. S1-S2 stated they took all the necessary precautions to prevent the allegation from occurring. This issue had nothing to do with the staff working at the facility. The facility staff took additional measures and implemented a plan to handle this situation and prevent this type of incident from happening again in the future. S1-S2 self-reported the allegation to Community Care Licensing Division, Harbor Regional Center, Adult Protective Services, Long Term Care Ombudsman, and Long Beach Police Department, all the appropriate agencies were notified in a timely manner.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 deemed unsubstantiated.

There were deficiencies cited.

Exit interview conduct.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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