198603020-5-9-2023-28-AS-RORN-CSZUS9-20230621154957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603020
Report Date: 05/09/2023
Date Signed: 05/09/2023 04:46:03 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
05/04/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230504092646

FACILITY NAME:	FMJVITACARE1 CORP		FACILITY NUMBER:	198603020
ADMINISTRATOR:	ALICE REYES		FACILITY TYPE:	735
ADDRESS:	2718 BLAKEMAN AVE		TELEPHONE:	(909) 641-7109
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY:	4	CENSUS: 4	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Liezl Ann Fernandez		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Staff member hit resident in care
Staff member is harrasing resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted an initial 10 days complaint to obtain the information for the above allegation(s). LPA met with House Manager Liezl Ann Fernandez and explained the reason of the visit and Shortly after, the administrator Alice Reyes arrived and assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviwed administrator, two staff (S1-S2) in the facility and staff (S3)via telephone, four clients (C1-C4), Regional Center staff and obtained documents for C1 including face sheet, Individual Personalized Plan (IPP) and Behavioral Consultant Report and copy of staff training.

The investigation revelaed of the following: Allegation#1 "Staff member hit resident in care" LPA interviewed clients and two out of four clients denied the allegation and reported all staff are nice to them and they never witnessed any staff hit clients in the facility and they all feel safe living in the facility.
(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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-20230504092646

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: FMJVITACARE1 CORP	FACILITY NUMBER: 198603020
	VISIT DATE: 05/09/2023

NARRATIVE

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LPA interviewed staff and denied the allegation and stated that they never witnessed any staff hit client in the facility. The staff also indicated that C1 likes to make false statement sometimes and C1 also would kick and hit staff sometimes. LPA also reviewed the record and it indicated that C1 has a history of blame others for being physically aggressive toward C1.

Allegation#2 "Staff member is harassing resident in care." LPA interviewed four clients and two out of four clients denied the allegation and reported that no staff ever harassing them. They never felt threatened by staff or never witnessed any staff poured orange juice on clients. They feel safe living in the facility and no staff ever harassed them. LPA interviewed staff and all denied the allegation. Administrator reported there was an incident happened last year. A client poured an orange juice on C1 and staff were witnessed but staff never did that to clients. Administrator also stated that all staff received training for personal right and they would never allowed staff harassed clients.

Based on the record review and interview conducted with clients and staff, 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 allegations are UNSUBSTANTIATED.

Exit interviewed conducted with House Manager Liesalann Fernandez and a copy of this report and appeal right was provided

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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