198603149-6-7-2024-28-AS-RORN-D66NBP-20240612101925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603149
Report Date: 06/07/2024
Date Signed: 06/07/2024 03:40:11 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 HOME		FACILITY NUMBER:	198603149
ADMINISTRATOR:	DIXON, PAMELA		FACILITY TYPE:	735
ADDRESS:	475 W WASHINGTON BLVD		TELEPHONE:	(213) 361-2792
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	4	CENSUS: 4	DATE:	06/07/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Raiko Vides - Direct Support Professional I (DSP I)		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff restrain clients for an extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to deliver findings to the above allegation. Upon arrival LPA met with Raiko Vides, Direct Support Professional I (DSP I) and explained the purpose of the visit. Staff Vides stated that the Administrator is unavailable to assist as she is out of town.

During the visit on 5/07/2024, LPAs B. Pena and D. Konishi 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).

During today's visit, LPA obtained copies of the staff and client rosters, delivered findings and issued deficiency.

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. *****CONTINUED ON LIC 9099-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: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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-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: 06/07/2024

NARRATIVE

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Interviewed staff denied the allegation and 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 to protect C1 from self injurious behavior. S1 stated that they do not have any other type of full body 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. Interviewed staff also stated that they receive personal rights in service training regularly. During LPA's visit on 5/07/2024, LPA conducted a tour of C1's room and observed the helmet stored in C1’s closet. LPA did not observe any full body restraint devices. LPA also observed C1 sitting on the chair in his bedroom without any type of restraints. LPA attempted to interview clients C1 through C4, but unsuccessful due to their cognitive abilities. There were no witnesses to the alleged incident. Review of documentation revealed that the facility did not submit or had an exception granted for protective helmet for C1.

Based on statements and interviews conducted with clients and 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 Raiko Vides, Direct Support Professional I.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

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