198603104-10-14-2022-28-AS-RORN-CKRKN3-20221101080225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603104
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:16:40 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
09/23/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220923085644

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:	10/14/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Alex DIel, Staff		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Unauthorized adult at the facility.
Facility staff member inappropriately used the resident's food.
Facility staff member transported residents to unauthorized location to conduct personal errand.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations.The purpose of the visit was discussed with staff Alex Diel.

The investigation consisted of: On 9/29/22, an initial 10-day visit was conducted in conjuction with Community Services Specialist Araceli Anguiano of the Eastern Los Angeles Regional Center. A physical plant tour of the facility and food supply of two (2) day perishables and seven (7) days non-perishables was inspected. Former client (C1) was interviewed telephonically. Family (F1 & F2), and staff (S2-S6) were interviewed. Clients (C2 & C3) are non-verbal and not interviewed. C1-C3 file documents [Indentification and Emergency Information/Face Sheet and Individual Program Plan (IPP's). Staff (S1) was interviewed today.

See LIC 9099C for report continuation.

Unsubstantiated

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: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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-20220923085644

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: 10/14/2022

NARRATIVE

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Allegation: Unauthorized adult at the facility. It is alleged that caregiver staff (S1's) family has visited the facility and has meals while at the facility without being fingerprint cleared. A total of six (6) staff were interviewed and all denied the allegation stating that staff family/visitors are not allowed inside the facility. Staff stated there have been times family members have visited the facility to pick up staff or drop off food only. Per Administrator/Licensee, staff visitors are not allowed inside if they have not been fingerprint cleared or associated. Two (2) family members were interviewed. Neither have witnessed staff (S1's) alleged unauthorized visitor at the facility. Staff (S1) stated that it has received a few visits in the past from family during its lunch break, but the visitor did not enter the home nor visited during nighttime hours. One (1) client was interviewed and stated that S1's partner visits at night and sleeps in the sofa. However, per client (C1's) Regional Center Individual Program Plan (IPP) the client has history of false statements i.e. "communicating to staff stories that are untrue and/or exaggerated to gain from others." Therefore, there is insufficient evidence to support this allegation.

Allegation: Facility staff member inappropriately used the resident's food. It is alleged that on numerous occasions caregiver staff (S1) cooks facility food and takes it to family's home and brings food to cook at the facility for it's own family. All staff interviewed denied taking the client's food to their own respective families. Per Administrator, the facility has more than enough food for clients and staff are allowed to eat the food as well if they desire, but it is not allowed to take left over food home. However, the staff are allowed to bring their own food and cook it at the facility. A small refrigerator in the garage is for staff use. Client (C1) stated it has accompanied S1 to family's home to drop off food. The name identified as S1's family member that is receiving the food is not correct. Family interviews revealed the information is hearsay. There is no evidence to prove the alleged allegation.

Allegation: Facility staff member transported resident to unauthorized location to conduct personal errand. It is alleged that caregiver staff (S1) has taken client (C1) to its family member's home to deliver food. All staff interviewed denied taking the client's on staff's personal errand outings. Staff are allowed to take clients on activity outings and errands to the mall, shopping stores, walks on the street, gym, and special outings in the facility vehicle. They are allowed to transport clients in their personal vehicle when the facility vehicle is not available. Staff are reimbursed for mileage. Family members stated they are aware that clients are transported on activity/errand outings related to client and facility needs in the facility vehicle or in the staff personal vehicle. There is insufficient evidence to corroborate this allegation.

Based upon record review and interviews conducted the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted & report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC9099 (FAS) - (06/04)

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