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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603149
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:30:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/30/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240430120133
FACILITY NAME:WASHINGTON HOMEFACILITY NUMBER:
198603149
ADMINISTRATOR:DIXON, PAMELAFACILITY TYPE:
735
ADDRESS:475 W WASHINGTON BLVDTELEPHONE:
(213) 361-2792
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:4CENSUS: 4DATE:
05/07/2024
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Melinda Pippens - AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff do not treat clients with dignity or respect.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced complaint visit to investigate the above allegations. Upon arrival LPAs met with Melinda Pippens, Administrator and explained the purpose of the visit.

During today’s visit LPAs toured the facility with the administrator, obtained client/ staff roster, documents in reference to Client #1, copies of staff in-service training about Personal rights, Clients rights and zero tolerance policy. LPAs interviewed Staff #1 (S1) – Staff #4 (S4). LPAs attempted to interview clients C1 through C4, but unsuccessful due to their cognitive abilities.

In regards to the allegation: “Staff did not treat resident with dignity or respect." It is alleged that a client was verbally abused. Interviewed staff denied the allegation. Staff interviewed stated that they never heard or witnessed any staff verbally abusing clients. S1 stated that the facility has zero tolerance policy with that type of behavior and that personal rights in service training are being conducted to staff on a regular basis. All staff interviewed stated that they treat residents with dignity and respect. *****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
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 4
Control Number 28-AS-20240430120133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WASHINGTON HOME
FACILITY NUMBER: 198603149
VISIT DATE: 05/07/2024
NARRATIVE
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Staff also stated that they receive personal rights in service training regularly. During the visit, LPAs witnessed C1 having a behavior and staff re-directed C1 by talking to him in a stern voice. There were no other witnesses to the alleged incident. Based on statements and interviews conducted with staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the 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 and a copy of this report was provided to the Melinda Pippens, Administrator.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/30/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240430120133

FACILITY NAME:WASHINGTON HOMEFACILITY NUMBER:
198603149
ADMINISTRATOR:DIXON, PAMELAFACILITY TYPE:
735
ADDRESS:475 W WASHINGTON BLVDTELEPHONE:
(213) 361-2792
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:4CENSUS: 4DATE:
05/07/2024
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Melinda Pippens - AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff restrain clients for an extended period of time.
INVESTIGATION FINDINGS:
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In regards to the allegation: “Facility staff restrain clients for an extended period of time.” It is alleged that a client was left alone in the rooms in full body restraints for several hours on multiple occasions. Interviewed staff stated that they never heard or witnessed a client left alone in the room in full body restraints. Interviewed staff stated that C1 uses a helmet as a protective device which do not prohibit C1's mobility but to protect C1 from self-injurious behavior. S1 stated that they do not have any other restraints other than the helmet that was ordered by C1's Physician. S1 also indicated that staff receive training on a weekly basis on how to use restraint and intervention techniques with the least restrictive intervention. Staff also stated that they receive personal rights in service training regularly. LPA attempted to interview a potential witness (W1) to the alleged incident, unfortunately W1 did not return LPA’s calls. Review of documentation revealed that the facility did not submit or had an exception granted for protective helmet for C1. There were no other witnesses to the alleged incident.
Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.
An exit interview was conducted, and a copy of this report was provided to the Administrator along with the Appeals Rights.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20240430120133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WASHINGTON HOME
FACILITY NUMBER: 198603149
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/17/2024
Section Cited
CCR
80072(a)(8)(F)(1.)
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80072...Personal Rights..(a) Except for..., each client shall have personal rights which include...(8) Not to be placed in any restraining device...Postural supports may be used.... 1.All requests to use protective devices shall be in writing ...The licensing agency shall be authorized to require additional documentation .. as specified in Welfare and Institutions Code Section 4646,...
This requirement is not met as evidenced by:
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Administrator will submit an exception request for protective helmet for C1 along with the required documents to CCL/LPA by POC due date.
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Facility has been using a helmet as a protective device for C1 however Administrator did not submit an exception request for protective helmet for C1.
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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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4