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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603020
Report Date: 02/03/2022
Date Signed: 02/03/2022 01:16:35 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 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
07/13/2021 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210713100726
FACILITY NAME:FMJVITACARE1 CORPFACILITY NUMBER:
198603020
ADMINISTRATOR:ALICE REYESFACILITY TYPE:
735
ADDRESS:2718 BLAKEMAN AVETELEPHONE:
(909) 641-7109
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:4CENSUS: 3DATE:
02/03/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alice Reyes (Administrator)TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff made an inappropriate comment towards a client while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted a subsequent visit to the facility to deliver complaint findings. Upon arrival, LPA met with Alice Reyes (Administrator) and explained the purpose of the visit.

During the initial visit on 07/14/21, LPA obtained a copy of the Staff schedule, Client roster and the Individual Program Plan, Medication log, Medical Assessment and Behavioral Report for Client #1. LPA interviewed Client #1 at 10:00 am in the backyard and interviewed Staff #1, #2 and #3 between 10:15 am to 10:50 am in the backyard. LPA took a tour of the facility with Staff #1 at 10:55 am.

In regards to the allegation: Staff made an inappropriate comment towards a client while in care. Interview with Client #1 indicate that Staff did not make an inappropriate comment towards Client #1. Interviews with 3 of 3 Staff indicated they did not make inappropriate comments towards Clients nor have Staff witnessed other Staff make inappropriate comments towards Clients. Continue to LIC9099C....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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 28-AS-20210713100726
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FMJVITACARE1 CORP
FACILITY NUMBER: 198603020
VISIT DATE: 02/03/2022
NARRATIVE
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Based on LPA's interviews, investigation revealed: 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 interviewed conducted with Alice Reyes and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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
CCLD Regional Office, 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
07/13/2021 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210713100726

FACILITY NAME:FMJVITACARE1 CORPFACILITY NUMBER:
198603020
ADMINISTRATOR:ALICE REYESFACILITY TYPE:
735
ADDRESS:2718 BLAKEMAN AVETELEPHONE:
(909) 641-7109
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:4CENSUS: 3DATE:
02/03/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alice Reyes (Administrator)TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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5
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9
Staff did not prevent a client from causing self harm while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted a subsequent visit to the facility to deliver complaint findings. Upon arrival, LPA met with Alice Reyes (Administrator) and explained the purpose of the visit.

During the initial visit on 07/14/21, LPA obtained a copy of the Staff schedule, Client roster and the Individual Program Plan, Medication log, Medical Assessment and Behavioral Report for Client #1. LPA interviewed Client #1 at 10:00 am in the backyard and interviewed Staff #1, #2 and #3 between 10:15 am to 10:50 am in the backyard. LPA took a tour of the facility with Staff #1 at 10:55 am.

In regards to the allegation: Staff did not prevent a client from causing self harm while in care. Interview with Staff and Client indicate that shavers for Client use is locked in a cabinet in the living room. Shavers are provided to Clients upon request. Once Clients complete the use of shavers, it is returned to Staff to be locked in the cabinet. Continue to LIC9099C.....
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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 28-AS-20210713100726
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FMJVITACARE1 CORP
FACILITY NUMBER: 198603020
VISIT DATE: 02/03/2022
NARRATIVE
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Interviews revealed that Client #1 popped a razor out of the shaver and used the razor to cause self harm. Staff neglected to notice a razor popped out of the shaver when Client #1 returned the shaver to Staff. At the time of the initial visit, LPA observed multiple cut wounds on both arms of Client #1.

Based on LPA's interviews and observations, investigation revealed: The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Alice Reyes and a copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210713100726
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FMJVITACARE1 CORP
FACILITY NUMBER: 198603020
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2022
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Licensee shall update Plan of Operations and provide training to all Staff regarding procedures to ensure that shavers/razor are safe for Client use and provide proof to the department by the POC date.
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This requirement is not met as evidenced by: Staff neglected to notice a razor popped out of the shaver when Client #1 returned the shaver to Staff resulting in Client #1 using the razor to cause self harm.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5