198603201-2-29-2024-28-AS-RORN-D3BTUZ-20240313150310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603201
Report Date: 02/29/2024
Date Signed: 02/29/2024 11:58:30 AM

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
02/27/2024 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240227092400

FACILITY NAME:	HEART TO HOME RESIDENTIAL FACILTY		FACILITY NUMBER:	198603201
ADMINISTRATOR:	MINES, JASMINE		FACILITY TYPE:	735
ADDRESS:	795 E ELIZABETH ST		TELEPHONE:	(626) 233-0725
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	6	CENSUS: 3	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Staff S 1		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Client sustained an unexplained bruise

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint investigation regarding the above allegation. LPA Trueman was met by Staff # 1(S1) and explained the purpose of the visit. This facility is licensed to served developmentally disabled clients 18 to 59 years old. Three (3) clients in the facility receive services from Frank D. Lanterman Regional Center.
LPA Trueman requested and obtained copies of Staff Roster (LIC 500), Client Roster (LIC 9020)
Staff #1 and Staff # 2 interviews and Administrator interviewed telephonically from 9:45 AM to 10:45 AM.
Attempts were made to interview Client's # 1 and # 2 who are both non-verbal and unable to respond to questioning. Client # C 3 was interviewed at 10:45 AM.
Client # 1's file was reviewed and the following documents were obtained: C1 Admissions Agreement, C1's Individual Program Plan (IPP) dated 6/05/23, Facility Assessment- Wound Log dated 02/01/24 to 02/29/24, Physician’s Report dated 3/23/23, photos of C1’s bruising on arm, and physical plant tour.
The investigation revealed the following. Regarding Allegation: Client sustained an unexplained bruise, based on interviews conducted, file review and information gathered ,the IPP dated 6/5/23 revealed C1 has

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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-20240227092400

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: HEART TO HOME RESIDENTIAL FACILTY	FACILITY NUMBER: 198603201
	VISIT DATE: 02/29/2024

NARRATIVE

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a history of self-injurious behaviors. States he will throw himself on the ground and it is difficult to get him up. He will hit his head against the wall or with his hand. Will also bite the collars of shirts when he is upset.

Interviews were conducted with Staff S1 and S 2 who stated that C 1 does have self injurious behaviors which could cause bruising. Stated it is probably from him hitting himself or hitting hands or arms on an object. Said they have not observed any other clients hitting or hurting C 1. Said they have never seen any staff abusive to any client.

Interview with Administrator who stated that C 1 will jump up and run really fast to the restroom. Said he had self injurious behaviors days before scratching his arm really bad. Stated her staff let her know right away and they documented the bruise. Also said he has very sensitive skin.

Attempts were made to interview C 1 and C 2 who are both non-verbal and unable to respond to questioning. C 3 stated that staff are good and they don't hit C1 or push him. Said they are treated well here.

It should be noted that Regional Center's findings were Unsubstantiated regarding Client sustained an unexplained bruise. Interview with Regional Center Representative who stated that there is no evidence to support the allegation with C 1 having self injurious behaviors.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and copy provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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