198603265-12-4-2023-28-AS-RORN-DARPH4-20241106101918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603265
Report Date: 12/04/2023
Date Signed: 12/04/2023 04:29:55 PM

Substantiated

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
12/01/2023 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20231201092149

FACILITY NAME:	GHENT		FACILITY NUMBER:	198603265
ADMINISTRATOR:	MORENO, DAISY		FACILITY TYPE:	735
ADDRESS:	18423 E. GHENT ST		TELEPHONE:	(626) 430-6101
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	4	CENSUS: 4	DATE:	12/04/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Cameron Finley		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted unannounced complaint visit to the facility to investigate the above noted allegation. LPA met with Cameron Finley. Shortly after House Manager and Administrator arrived. LPA explained the purpose of the inspection.

The investigation consisted of the following: LPA obtained copies of client and staff rosters, copy of Incident reports dated 11/30/23 and 12/01/23. LPA also reviewed Client #1's file and obtained copies of Face Sheet, Physician's report, most recent IPP, Appraisal/needs and services plan, Body assessment sheet / body chart. LPA also interviewed Client #2 (C2), Staff #1 (S1) to Staff #5 (S5). Client #1 (C1 ) was not interviewed as C1 is non-verbal. The facility is vendored through San Gabriel Valley/Pomona Regional Center.

Continue 9099C

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2023

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-20231201092149

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: GHENT	FACILITY NUMBER: 198603265
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/11/2023 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	80072 Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.	1 2 3 4 5 6 7	The Licensee / Administrator will ensure each client to be accorded safe, healthful and comfortable ..to meet their needs. Licensee / administrator will provide in service training to all facility staff for personal right and to reassure that everyone is following the facility polices,
	8 9 10 11 12 13 14	The requirement is not met as evidenced by LPA interviewed staff and observed that client (C1) sustained unexplained injuries / rug burns on their body / neck. Reason is unknown which poses an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14	and will explain the importance of internal documentation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231201092149

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: GHENT	FACILITY NUMBER: 198603265
	VISIT DATE: 12/04/2023

NARRATIVE

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Regarding the allegation that, “Resident sustained unexplained injuries while in care”, it was alleged that school staff noticed that C1 had severe burns his back which seemed like rug burns.
To investigate this allegation LPA spoke with the staff and client. Interviewed S1 stated that they noticed rug burns on C1 neck on 12/01/23 when they pick up C1 from the school. C1 is attending to Le Roy Haynes school. S4 who was with S1 at that day also confirm that they noticed the burn mark on the C1's neck. Before they didn't notice any marks on C1's body / neck. Interviewed administrator and house manager stated that facility staff are doing body check every day and when clients are outing. LPA obtained copies of Body assessment sheet / body chart for C1 dated 11/19/23, 11/30/23, 12/1/23 to 12/4/24.
Administrator stated that they didn't observe any rug burns / marks on C1's body before 12/1/23. On 12/1/23 at 11:00 am Administrator received the phone call from school staff who told the administrator that they noticed rug burns on C1's neck. On the administrator question that how is C1 is feeling, the school staff said that C1 is ok and there is no sign of discomfort or pain. At 1:00 pm school staff called the administrator again and ask for transportation for C1, because of C1's behavior. C1 refused to go in the school bus. S1 and S4 transported C1 back to facility. After C1 came back the administrator applied first aid and C1 was monitored throughout the day. Interviewed S5 stated that they noticed rug burns on C1's neck after C1 returned back from the school on 12/01/23. Interviewed C2 stated that they scared of C1 and doesn't want to talk about C1. C2 stated that C1 very aggressive and bite everyone.
A review of facility records conducted revealed that although the staff conducted a body check based on Facility policy, the information was not documented daily in the facility records / Body assessment sheet / body chart. All the information is in home base, but not in the facility chart. LPA advise the administrator to have all the information on the facility chart.
All interviewed staff reported they observed C1 had unexplained rug burns on C1 neck but unable to find out what had happened.
Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

Exit interview was conducted with Administrator. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

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