198603289-8-22-2023-28-AS-RORN-CX5NHR-20231031102909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603289
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:21:12 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
08/15/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230815162916

FACILITY NAME:	KAISER BEHAVIORAL CENTER WEST COVINA		FACILITY NUMBER:	198603289
ADMINISTRATOR:	INIGUEZ, JOANNA		FACILITY TYPE:	775
ADDRESS:	1532 AMAR ROAD STE B		TELEPHONE:	(626) 945-0790
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	75	CENSUS: 37	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Robert Reyes		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not properly supervising client in care resulting in client sustaining unexplained bruising.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Lead Supervisor Robert Reyes and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Lead Supervisor Robert Reyes, Staff 1-3, Clients 1-4 (C1-4), telephone interview with San Gabriel Pomona Regional Center Service Coordinator (SC) Ethan Chan, and telephone interview with C5 Family Member 1-2 (C5 FM1-2). LPA was not able to properly interview C5 by telephone as C5 is non verbal. LPA obtained copies of Staff and Client Rosters. LPA reviewed C5's file and collected copies of documents relevant to the investigation. LPA conducted a tour of facility which included observations of various activity rooms, Cafeteria, 2 kitchens, changing room, and offices.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 5

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
08/15/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230815162916

FACILITY NAME:	KAISER BEHAVIORAL CENTER WEST COVINA		FACILITY NUMBER:	198603289
ADMINISTRATOR:	INIGUEZ, JOANNA		FACILITY TYPE:	775
ADDRESS:	1532 AMAR ROAD STE B		TELEPHONE:	(626) 945-0790
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	75	CENSUS: 37	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Robert Reyes		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not reporting incidents involving client as required.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20230815162916

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: KAISER BEHAVIORAL CENTER WEST COVINA	FACILITY NUMBER: 198603289
	VISIT DATE: 08/22/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Staff are not reporting incidents involving client as required, it is alleged that staff did not report concerns regarding bruising that was observed on C5. The bruising that was observed beginning on or around April, June, July and August of 2023, was allegedly reported to facility staff by C5 FM1-2 and staff did not have an explanation regarding how C5 got the bruising and facility staff just stated that they do not know how it happened or that C5 comes to the facility with the bruising. Facility staff did not report any of the incidents were bruising was reported to either San Gabriel Pomona Regional Center or to Community Care Licensing Division. Interview conducted with Lead Supervisor Robert Reyes revealed that staff did not report the incidents regarding C5's bruising to either SGPRC or to CCLD as staff did not witness any incidents in April, June, July or August 2023 and were not aware of how C5 sustained the bruising. Mr. Reyes stated that the only incident that was noted in C5's notes was the bruising reported on 8/11/23 but was not reported to SGPRC or to CCLD. Mr. Reyes stated that on 8/15/23 he had a meeting with SGPRC and C5 FM1-2 and a plan was created to address the concerns. Mr. Reyes stated that the facility will conduct daily body checks of C5 upon arrival and departure of day program and will document and report anything of concern to SGPRC, CCLD and C5 FM1-2. C5 continues to be a client of the day program. LPA did not find any evidence that an incident report was submitted to CCLD or any other applicable agencies within the required time frame regarding any of the reported bruising sustained by C5 for the time frames of April, June, July or August 2023.

Based on LPA review of records and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 Chapter 3 are being cited on the attached LIC9099D.

Exit interview conducted with Program Manager Vanessa Mejia. A copy of this report and Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230815162916

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: KAISER BEHAVIORAL CENTER WEST COVINA	FACILITY NUMBER: 198603289
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/01/2023 Section Cited CCR 82061(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements. Upon the occurrence, during the hours the day program is providing services to the client, of any unusual incident which threatens the physical or emotional health or safety of any client, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing specified information shall be submitted to the licensing agency within seven days following the occurrence of the event.	1 2 3 4 5 6 7	Licensee/Program Director agrees to self certify to Title 22 regulation, conduct in service training with the staff regarding reporting requirements and provide proof of correction with training log and procedures, submit to CCLD by POC due date.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on LPA record review and interview with Lead Supervisor, LPA did not find evidence of documentation of incident reporst submitted to Licensing for any incidents reporting bruising on C% from April, June, July and August of 2023, which poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	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: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230815162916

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: KAISER BEHAVIORAL CENTER WEST COVINA	FACILITY NUMBER: 198603289
	VISIT DATE: 08/22/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Staff are not properly supervising client in care resulting in client sustaining unexplained bruising, it is alleged that beginning on or around April 2023, C5 started sustaining unexplained bruising after attending the facility and there have been incidences observed in April, June, July and August of 2023. It is alleged that these concerns were reported to facility staff and staff did not have an explanation regarding how C5 got the bruising and facility staff just stated that they do not know how it happened or that C5 comes to the facility with the bruising. Interviews conducted with 4 out of 5 clients revealed that staff properly supervise clients in care and staff have never physically hurt them or any client that attends the day program. They stated that staff are very nice and take good care of clients and help them when they need assistance. C5 was not interviewed as client is non verbal. Interviews conducted with 4 staff revealed that staff properly supervise all clients in care. Staff denied that C5 or any other client sustained bruising while attending the day program. Staff stated that that nothing unusual occurred with C5 in April, June, July and August of 2023 that might have caused C5 to sustain bruising. S3 stated that on 08/11/23, as C5 arrived at the program, S3 noticed bruising on C5's right arm from the elbow down. S3 reported their observations to facility supervisor and observations were noted down. Interview conducted with SGPRC SC revealed that their investigation did not reveal that the bruising occurred at the day program or at the home of C5 and also stated that C5 has behaviors such as biting themselves, physical aggression towards others, banging their head and property destruction. Interview with with C5 FM1-2 revealed that C5 does bite themselves on both wrists. LPA's review of C5's IPP corroborated the information regarding self injurious behavior. LPA also observed that C5 takes a medication that might cause bruising.

During facility tour, LPA observed clients participating in activities and did not observe anything of concern. LPA observed the facility to be clean during the time of the visit and did not observe any items obstructing any doors or passageways. Based on statements gathered from interviews conducted with staff, SGPRC staff, C5 FM1-2 and LPA observations, there was not enough supportive evidence to concur with the reported 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 held. A copy of the report was provided to Program Manager Vanessa Mejia.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5