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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603128
Report Date: 08/19/2025
Date Signed: 08/19/2025 04:30:52 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
08/11/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250811124750
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: DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mirna Alderete - House ManagerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not prevent client from wandering from the facility
Staff are out of ratio
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with House Manager. Administrator arrived shortly after. The reason for the visit was explained.

The investigation consisted of the following: LPA Margaryan obtained a copies of the staff roster, clients roster, reviewed Client 1 - Client 3 (C1) - (C3) files and obtained copies relevant documents. Interviews conducted with Administrator, House Manager and SC from SGPRC. (C2) and (C3) were at the Day Program at the time of visit. C1 was present but refused to be interviewed.

Continue 9099C

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 2
Control Number 28-AS-20250811124750
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: 08/19/2025
NARRATIVE
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Allegation: Staff did not prevent client from wandering from the facility. It was alleged that C1 left the facility three weeks ago and hasn't returned and no one knows where the client is.

During this investigation, LPA interviewed Administrator, House Manager and SC from SGPRC. They denied the allegation. Interviewed Administrator stated that no clients at the facility is wandering. They stated that C1 was out of the facility for a couple of days in the months of July and August, and the facility staff was aware of it. C1 was in contact with facility administration and kept Administrator and House Manager aware of their whereabouts. Interviewed House Manager stated that currently 2 clients at the facility (C1 and C2) that checking themselves in and out. House Manager stated at the time that C1 was out of the facility for a couple of days, C1 was in contact with them via text messages and ph. calls. LPA was provided with copies of client Sign In/Out Sheets and screen shots of text messages. C1's file was reviewed. The file indicated that C1 can be out of the facility on his/her own. This is not a "lock down" facility and clients are able to leave the facility. Interviewed SC stated that C1 currently living at the facility and is able to go out in the community independently and does not have require a 1:1. At the time of visit C1 was at the facility but refused to be interviewed. C2 and C3 were at the Day Program. Interviews and information obtained does not corroborate this allegation.

Allegation: Staff are out of ratio. It was alleged that there are three clients to one staff. Staff don't know if clients need to have one to one supervision and don’t have access to the clients IPPs.

During this investigation, LPA interviewed Administrator and House Manager. Interviewed Administrator stated that staff are always available to meet client’s needs at the facility. Interviewed Administrator and House manager stated that there are always at least two staff at the facility. LPA reviewed clients files and confirmed that the facility is operating within the required ratio. Review of IPPs shows that facility clients at the facility do not require 1:1 or 1:2 supervision. Facility Administrator is also on-call 24/7 if needed at the facility. Administrator and House Manager indicated that during orientation staff is informed about Administrator and House Manager availability if needed. Administrator and House Manager make themselves available if needed. Administrator stated that facility staff have a access to any information regarding clients including IPPs. LPA was unable to interview clients. C1 refused to be interviewed and C2 and C3 were at the Day program. Interviews and information obtained does not corroborate this allegation.

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 allegation is UNSUBSTANTIATED.


Exit interview conducted and the copy of report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2