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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603128
Report Date: 10/10/2025
Date Signed: 10/10/2025 01:25:02 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
06/17/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250617084101
FACILITY NAME:AZUSA HOMEFACILITY NUMBER:
198603128
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:722 W 6TH STTELEPHONE:
(626) 633-1610
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:3CENSUS: 3DATE:
10/10/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mirna Alderete - Program ManagerTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff makes inappropriate comments to resident.
INVESTIGATION FINDINGS:
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This report supersedes report dated 06/23/25. The reason for superseding is to correct section on 9099D page and does not change the complaint investigation report findings recorded on 06/23/25. The findings remain as Substantiated.
Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent visit at the facility and met with Program Manager Mirna Alderete and explained the reason for today’s visit.

The investigation consisted of the following: LPA Margaryan obtained copies of the staff roster, clients roster, reviewed C1 file and obtained copies of relevant documents. Interviews conducted with Administrator, Staff 1 (S1) and Staff 2 (S2), Client 1 (C1) and Client 2 (C2). LPA attempted to interview C3, but C3 didn't answer LPA's questions. Staff 2 was interviewed over the phone.

Continue 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 3
Control Number 28-AS-20250617084101
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: AZUSA HOME
FACILITY NUMBER: 198603128
VISIT DATE: 10/10/2025
NARRATIVE
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In regards to the allegation. Staff makes inappropriate comments to clients. It was alleged that staff (S2) made inappropriate comments to C1 such as who C1 is having sexual relations with and if C1 has had sex before. This made C1 feel extremely uncomfortable and C1 does their best to avoid S2 when S2 is working.

Interviewed Administrator and S1 who stated that as of this morning 06/23/25, they were not aware of S2 made an inappropriate conversation with C1 about C1's sex life. Interviewed Administrator and S1 who stated that they did not witness the conversation but this morning C1 told S1 that S2 made inappropriate comments about C1's sexual activity and it made C1 feel very uncomfortable. Interviewed Administrator stated there is currently an open investigation at different home with a similar allegation that involved S2, and it is under SGPRC and facility investigation. Administrator stated that S2 currently is suspended from work until end of the investigation. Interviewed C1 stated that S2 made them very uncomfortable with the questions that S2 asked about C1's sexual life. C1 stated that they brought S1's attention this morning. LPA spoke with S2 over the phone and S2 admitted that they asked questions about C1's sexual life and ask if C1 has had sex before.

Based on LPA's interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

See the attached 9099 D

Exit interview held. A copy of the report and appeal rights were provided to Program Manager.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20250617084101
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: AZUSA HOME
FACILITY NUMBER: 198603128
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2025
Section Cited
CCR
80072(a)(1)
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Personal Rights. (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons.
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Administrator shall provide a copy of
In-service training for all staff regarding "Personal Rights," by POC due date. Proof of correction will be email to LPA.
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This requirement is not met as evidenced by: Investigation has revealed that S2 made inappropriate comments towards C1, which made C1 very uncomfortable. This poses a potential health and safety risk to the clients in care.
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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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3