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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603035
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:53:45 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
09/20/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220920102820
FACILITY NAME:PUENTE HOMEFACILITY NUMBER:
198603035
ADMINISTRATOR:YASHICA MORROWFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(909) 596-5360
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 4DATE:
10/11/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angela Synder TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff abused resident resulting in injury/bruising.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to deliver the investigation finding. LPA met with Assistant Administrator Angela Synderand explained the reason of the visit

The Investigation consisted of the following: On 09/20/22, LPA Wong conducted a health and safety check which included a tour of the facility and observed the food supplies and obtained copy of C1 and C2's face sheet, identification and emergency information, Individual Program Plan (IPP) 30 days evaluation dated on 8/16/22 and 7/19/22, regional center monthly QBMP Evaluation dated on 6/30/22, data collection notes from 9/17/22 to 9/20/22. On 9/21/22, LPA Wong interviewed four clients (C1-C4), administrator and two staff (S1-S2). LPA also interviewed additional three staff (S3-S5) and C1’s day program director via phone.

See LIC9099-C for contination

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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 2
Control Number 28-AS-20220920102820
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: PUENTE HOME
FACILITY NUMBER: 198603035
VISIT DATE: 10/11/2022
NARRATIVE
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The investigation revealed of the following: In regard to the allegation “Staff abused resident resulting in injury/bruising. LPA interviewed four clients and three out of four clients reported that no staff was mean or hit the clients in the facility. LPA interviewed staff and all staff denied the allegation and reported that the big black bruise on C1's left arm was due to the blood drawn on Friday 9/16/22 and C1 admitted to the day program director and all staff and administrator in the facility about the big black bruise on the left arm was from the blood drawn. The administrator reported the incident was happened on Sunday morning 09/20/22, the nurse who drew her blood on Friday called C1 again on Sunday morning and reported they could not draw her blood successfully the other day and they need to come back and do it again. C1 was very mad after the phone call and she hung up on the nurse. Staff tried to explain to C1 and told C1 the nurse needs to schedule the appointment but C1 can refuse when the nurse arrived. The phone call triggered C1’s behavior and C1 came toward to the staff with hands up and with a closed fist. Staff tried to calm C1 down and asked C1 to go back to her room but C1 refused and attempted to attack the staff, therefore the staff had to complete CPI by holding C1’s arm and escorted C1 back to the room. The CPI was not even two minutes full. When C1 was back to the room and C1 called the police. The police came and checked on C1, and no injury was found and determined no crime was occurred.

Based on the interviews conducted with staff and clients and documents reviewed, 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 Interview conducted and a copy of this report and appeal right was provided to Assistant Administrator Angela Synder.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2