198603227-8-10-2023-28-AS-TVAO-CUWSU9-20230821141045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603227
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:27:14 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
03/29/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230329112501

FACILITY NAME:	WATERS PLACE		FACILITY NUMBER:	198603227
ADMINISTRATOR:	WATERS, LUTHER		FACILITY TYPE:	735
ADDRESS:	2177 WHITE ST		TELEPHONE:	(626) 696-3910
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	3	CENSUS: 3	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Luther Waters - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility failed to prevent sexual touching by one client to another client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with administrator and explained the reason for the visit.

The investigation consisted of the following: On 3/29/23 LPA Flores conducted a health and safety check with Jusitn Willard Staff and noted deficiencies on a case management visit. LPA requested the following documents: admissions agreement, physician's report, individual service (program) plan, behavioral analyst reports, incident reports, for client #1(C1), and #2(C2). On 4/25/23 Investigator Laarni Santiago from the Investigation Bureau Department (IB) was assigned the investigation and conducted the following interviews. On 4/13/23 conducted interviews with 2 staff and 3 clients. On 6/20/23 contacted Pasadena Police Department. On 6/22/23 interviewed 3 additional staff. On 6/23/23 IB attempted to interview Service Coordinator from Lanterman Regional Center and interviewed Nurse Consultant. On 6/27/23 an additional facility staff was interview. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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-20230329112501

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: WATERS PLACE	FACILITY NUMBER: 198603227
	VISIT DATE: 08/10/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility failed to prevent sexual touching by one client to another client. It is alleged client is being touched by another client in the chest area and would like it to stop. On 4/13/23 Administrator stated perpetrator (C2) had been showing inappropriate behaviors towards victim (C1) for about six months. On 2/9/23, C2 touched C1’s chest and on 3/21/23, C1 stated C2 had touched C1’s chest again. During a visit from facility’s nurse consultant on 3/24/23, C1 reported to nurse consultant that "C2 touched C1’s chest”. Interviews with staff revealed, 5 out of 5 staff stated to have been aware of C2 touching C1’s chest area. Staff redirected C2, upon observation of C2 attempted to interact with C1. Staff were not able to verify if the behavior was to gain sexual gratification or to “annoy” C1. During interview conducted with Administrator, administrator ensured there is sufficient staff available to supervise. Interview with C1 revealed that C2 had “grabbed” C1’s chest and C1 “did not like it”. C2 had asked C1 several times to “go away” and behavior stopped. During interview with C2, C2 stated to know the behavior was inappropriate, C2 was doing it to “joke around” and it had stopped. Interview with additional client (C3) noted C2 has inappropriate behaviors and staff are always available to redirect the behavior and provide supervision. On 6/20/23 contact with Pasadena Police Department (PPD) revealed a visit by PPD was conducted on 3/24/23 to follow up on a different concern. During PPD's visit Administrator shared C2’s behavior towards C1 with police officers. However, no formal report was open, and the concern was forward to the detectives at that time. On 3/26/23 Nurse Consultant stated C1 had reported that C2 had “touched C1’s boobs” and denied being touched anywhere else.
Document review revealed on 2/10/23 an incident report was submitted to the department reporting C2 touched C1 in the chest and rear end area on 2/9/23. On 3/21/23 an incident report was submitted to the department reporting C1 had notified staff that C2 had touched chest area. C2’s Triennial Individual Program Plan dated 8/19/2019 does not note unusual sexual behaviors. Per interviews conducted and document review, there is no evidence that the touching was to obtain sexual gratification. Therefore, there is not enough 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 was conducted with Luther Waters administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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