198603273-5-6-2022-28-AS-WSHO-CECP8K-20220512110540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603273
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:54:56 PM

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
04/18/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220418100717

FACILITY NAME:	BRADBOURNE		FACILITY NUMBER:	198603273
ADMINISTRATOR:	SMITH, JAY		FACILITY TYPE:	735
ADDRESS:	1332 BRADBOURNE		TELEPHONE:	(855) 302-3331
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	4	CENSUS: 4	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Assistant Administrator / Joey Perez		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident is being physically abused while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Resident is being physically abused while in care.". Upon arriving at the facility, LPA met with Assistant Administrator / Joey Perez who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 4/28/22, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Assistant Administrator, Staff members 1 - 5 (S1 - S5) and Clients 1 - 3 (C1 - C3). LPA attempted to interview Client 4 (C4) but was unsuccessful as C4 is non verbal. Also, copies of the following documents were obtained in reference to C1;

• Unusual Incident/Injury Reports dated 4/14/22 and 4/16/22 • Body Assessment Sheet for period 4/14/22 - 4/16/22

(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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-20220418100717

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: BRADBOURNE	FACILITY NUMBER: 198603273
	VISIT DATE: 05/06/2022

NARRATIVE

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The investigation revealed the following;

Allegation: Resident is being physically abused while in care. The details of this allegation states that on 4/14/22, S1 hit C1 with a thermometer. It is unknown what part of the body C1 was allegedly hit.

Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. All Clients and Staff interviewed denied of such incident happening involving S1 and C1. LPA learned that on 4/14/22, C1 began having combative behaviors which lasted for three days. C1 was being verbally and physically aggressive towards staff and was having self injurious behaviors. The Temple City Sheriff's Department came to the facility twice and did a health and safety check on C1 and during the second visit conducted on 4/16/22, C1 was placed on a 5150 hold (for being a danger to himself and others) and transferred to Olive View - UCLA Medical Center, where he was hospitalized. C1 was discharged from Olive View - UCLA Medical Center on 4/20/22 and returned back to the facility. Based on the information gathered, there is insufficient evidence to support the allegation to be true.

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.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

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