198603201-8-15-2023-28-AS-TVAO-CV8PBX-20230831111105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603201
Report Date: 08/14/2023
Date Signed: 08/15/2023 07:13:37 AM

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
07/20/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230720114729

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: 4	DATE:	08/14/2023
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Staff #3		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit to deliver findings on 08/14/23 regarding the above allegation(s). LPA Ramirez was met by Staff #3(S3) and explained the purpose of the visit. This facility is licensed to served developmentally disabled clients 18 to 59 years old. Four (4) clients out of the four (4) clients in the facility receive services from Frank D. Lanterman Regional Center.

The investigation consisted of the following: Initial complaint investigation was conducted on 7/21/23 by LPA Ramirez. LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Client Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Client #3 interview (C3), C1 Face sheet, C1 Admissions Agreement, C1 Individual Program Plan (IPP) dated 6/05/23, Facility Assessment- Wound Log dated 5/2/23 to 7/14/23, Facility ABC Data Sheet dated 6/5/23 to 8/6/23, Physician’s Report dated 3/23/23, Medical report from College Hospital dated 2/3/23, Staff in Service-Training dated 7/31/23 and 8/10/23, photos of C1’s bruising on arms and torso, and physical plant tour.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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-20230720114729

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: HEART TO HOME RESIDENTIAL FACILTY	FACILITY NUMBER: 198603201
	VISIT DATE: 08/14/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This investigation revealed the following. Regarding Allegation: Resident sustained unexplained injuries while in care. It is alleged C1 sustained unexplained bruising while in care. C1 was admitted into the facility on 5/2/23. C1 is ambulatory and requires some assistance with daily activities. IPP dated 6/5/23 revealed C1 has a history of self-injurious behaviors. During the month of June 2023, LPA Ramirez counted and reviewed twelve (12) documented self-injurious behaviors for C1 on C1’S ABC Data Sheet. During the month of July 2023, LPA Ramirez counted and reviewed eight (8) documented self-injurious behaviors for C1 on C1’S ABC Data Sheet. Four (4) out of four (4) staff deny allegation. All staff interviewed revealed C1 will make a closed fist and hit C1’s own chest and head. Staff revealed they will redirect C1 and use walks and healthy food as form of redirect when C1 exhibits these behaviors. LPA Ramirez attempted to interview C1. Due to C1 being non verbal, communication was limited. LPA Ramirez did not observe bruising while attempting to communicate with C1. LPA Ramirez obtained copies of recent in-service staff training on Protective Strategies/ Antecedent and Functions of Behavior. 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.

No deficiencies are being cited during visit. Exit interview was conducted with S3. A copy of this report was provide via email due to printer problems.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2