198603104-8-31-2022-28-AS-MVAO-CJGQLW-20220921121637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603104
Report Date: 08/31/2022
Date Signed: 08/31/2022 04:57:54 PM

Substantiated

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
08/26/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220826150013

FACILITY NAME:	TOMINES ADULT RESIDENTIAL FACILITY I		FACILITY NUMBER:	198603104
ADMINISTRATOR:	TOMINES, JONATHAN		FACILITY TYPE:	735
ADDRESS:	6234 N BURTON AVE		TELEPHONE:	(626) 848-8836
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	4	CENSUS: 2	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	02:53 PM
MET WITH:	Alex Diel, DSP		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

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Staff is verbally abusive to clients in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Galarza & Yang conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with staff Yolanda Cueto.

The investigation consisted of: A physical plant tour of the home, health and safety check of clients in care, and interviews. Staff (S2- S7) were interviewed. An interview with staff (S1) was attempted. However, S1 was suspended today pending investigation findings and did not return phone calls. A telephonic interview was conducted with client (C1) who is presently at a higher level care facility, as well as San Gabriel/Pomona Regional Center staff. Staff (S1's) file records [Personnel Record, Notice of Disciplinary Action (8/11/22), Policies and Procedures, training logs, Health Screening Report, Statement of SOC 341, LIC 9052 Employee Rights, LIC 508 Criminal Record Statement, LIC 500 Personnel Report, and Register of Facility Clients.

See LIC 9099C for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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-20220826150013

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: TOMINES ADULT RESIDENTIAL FACILITY I	FACILITY NUMBER: 198603104
	VISIT DATE: 08/31/2022

NARRATIVE

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Allegation: Staff is verbally abusive to clients in care. It is alleged that DSP staff (S1) verbally abuses clients in care by yelling and using foul language. Staff (S1) yells f**k and s**t regularly. According to interviews conducted, S1 is very aggressive and does not have patience with clients. It was reported that both clients and staff feel nervous around staff (S1) because the staff is often angry.Three (3) out six (6) staff confirmed the allegation. One (1) client was interviewed and stated that staff (S1) often yells at everybody and it causes fear in the client. Only verbal abuse was reported.

Administrator and Assistant Administrator reported no knowledge of alleged abuse. However, on August 19, 2022 staff (S1) was re-assigned to work at licensee's other facility because new staff were hired to work at this facility. This facility was S1's primary job location. Administrator stated that S1 was suspended earlier today because the facility has a Zero Tolerance Policy for Consumer Abuse or Neglect; which protects against abuse or neglect treatment of clients.

Based on interviews conducted and observations, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D.

Exit interview was conducted with DSP staff Alex Diel. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220826150013

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: TOMINES ADULT RESIDENTIAL FACILITY I	FACILITY NUMBER: 198603104
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/09/2022 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.	1 2 3 4 5 6 7	Administrator shall conduct a staff in-service training on Personal Rights, Zero Tolerance, and Reporting Requirements. Submit training log with staff signatures.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on interviews conducted DSP staff (S1) verbally abuses clients in care by yelling and using foul language; which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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