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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603273
Report Date: 06/01/2023
Date Signed: 06/01/2023 04:03:01 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
03/04/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220304085352
FACILITY NAME:BRADBOURNEFACILITY NUMBER:
198603273
ADMINISTRATOR:SMITH, JAYFACILITY TYPE:
735
ADDRESS:1332 BRADBOURNETELEPHONE:
(855) 302-3331
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:4CENSUS: 3DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff / Terry Jelk
Assistant Administrator / Joey Perez		TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident sustained injury 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 sustained injury while in care". Upon arriving at the facility, LPA met with Staff / Terry Jelk and was later joined by the Assistant Administrator / Joey Perez who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 3/7/22 and 5/31/23, in reference to the allegation listed above. During the course of the investigation, interviews were conducted of various persons to include the Assistant Administrator, Clients 1 – 3 (C1 - C3), Staff 1 and 2 (S1 and S2) and Service Coordinator / Michelle Ortega from San Gabriel/Pomona Regional Center (SGPRC). LPA made an attempt to interview Client 4 (C4) but was unsuccessful due to C4 being non-verbal. LPA made multiple attempts to interview Staff 3 (S3) via telephone but was unsuccessful as S3 did not return calls. S2 and S3 no longer work at Bradbourne. C1 is no longer a resident of Bradbourne and the interview of C1 was conducted at the new facility where he resides. Also, copies of the following documents were obtained and reviewed in reference
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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-20220304085352
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: 06/01/2023
NARRATIVE
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to C1 and S1;
• Client Information Sheet • Agreements and Consent for Medical Treatment • Personal Rights • Individual Program Plan (IPP) • Behavior Consultant Notes • Special Incident Report • Personnel Record • Employee Rights • San Gabriel/Pomona Regional Center • Zero Tolerance Policy • Direct Support Continuing Education • On-The-Job Training • Criminal Record Statement • Staff Roster • Client Roster

The investigation revealed the following;
Allegation: Resident sustained injury while in care. The details of this allegation states that S1 punched C1 on the right eye causing a black eye.

Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. On 1/27/22, at approximately 1:30pm, the Assistant Administrator brought supplies/rewards for the clients token system. C1 helped S1 put away the rewards and during the process C1 removed some rewards and put them in his pocket. S1 redirected C1 and asked C1 to return the items but C1 continued to put items in his pocket. C1 began calling S1 racist comments at which time S1 ignored the comments made by C1. As S1 turned away, C1 attacked S1 from behind and began pulling her hair and shirt and striking S1. S1 called other staff for help as she attempted to remove herself away from C1 and during the process C1 was hit in the right eye causing a black eye. S2 and S3 arrived after hearing S1 call for help and assisted by redirecting C1 to his room. The incident took place in the kitchen. During the interview of C1, C1 admitted to attacking S1 and trying to hurt S1. C1 denied the injury caused by S1 as intentional and stated that it was an accident and happened while S1 was trying to remove herself away from C1. During the interview of S1, S1 denied hurting C1 intentionally and her statement corroborated with the statement of C1 as the incident being an accident. Statements obtained from other staff and clients described S1 as being caring and professional. After reviewing the facility file of S1, LPA did not observe prior disciplinary actions/write ups against S1. The Temple City Sheriff’s Department and SGPRC were involved and conducted multiple visits at the facility and no signs of abuse were found regarding the incident involving S1 and C1. Based on the investigation conducted, there is insufficient evidence to prove the above mentioned 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 to the Assistant Administrator.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2