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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603289
Report Date: 07/07/2025
Date Signed: 07/07/2025 03:23:44 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
06/06/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250606135804
FACILITY NAME:KAISER BEHAVIORAL CENTER WEST COVINAFACILITY NUMBER:
198603289
ADMINISTRATOR:MEJIA, VANESSAFACILITY TYPE:
775
ADDRESS:1532 AMAR ROAD STE BTELEPHONE:
(626) 945-0790
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:75CENSUS: 33DATE:
07/07/2025
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Vanessa Mejia, Program ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not provide adequate transportation for the clients.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent visit for the above-mentioned allegation. LPA meet with Vanessa Mejia who assist with the visit. The purpose of the visit was explained.

The investigation consisted of the following: At the time of initial visit LPA Margaryan obtained copies of Staff and Clients Rosters, interviewed Staff 1 to Staff 3 (S1 to S3). LPA also obtained copies of relevant documents. A tour of the facility was conducted.

Continue 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
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 3
Control Number 28-AS-20250606135804
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: KAISER BEHAVIORAL CENTER WEST COVINA
FACILITY NUMBER: 198603289
VISIT DATE: 07/07/2025
NARRATIVE
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The investigation revealed the following: in regard to the allegation “Staff did not provide adequate transportation for the clients.” It was alleged that clients did not provide adequate transportation and were not picked up by the Day program several times.

Interviewed staff stated that the program provide adequate transportation to clients. Interviewed S1, S2 and S3 stated the program has nine passenger vehicles to transport the participants to and from their homes. They stated that sometimes (not often) Program had to cancel participant services either on the morning of the programming day or the day before scheduled services. These cancellations are sometimes due to staff absences. Other times program staff are the ones who are cancelled on, and program staff are unaware until they arrive at a family home and/or residential facility. These sorts of cancellations are due to a behavior at home, doctor/specialist appointments or the individual being sick. Interviewed staff stated it is always their goal to be transparent and work with the families and residential facilities of those individuals attending their program. Interviewed S1 stated they have communicated with family homes, residential facilities, Regional Center and do not take cancellations lightly, but they believe it is important to remain compliant with their approved program design and regulations. It is imperative that the 3:1 ratio be always maintained due to the type of service and support that is needed by those referred to and actively attending the day program. It is for this reason, they place priority on maintaining 3:1 ratio always rather than attempting to provide transportation to all individuals on the roster and provide inadequate care. Interviewed S2 stated they always notify the families and facility staff about cancelations and have had meetings about how to rotate cancelations, so it does not target any one person unfairly. Interviewed staff stated they take a very measured approach and are sensitive to the needs of the participants, parents/family members and residential facilities and they understand that the individual they support has a choice of where to attend and can advocate for a different program if they feel it necessary to seek other options. All interviewed staff stated Program staff are very mindful of any cancellation and have always attempted to minimize them. Furthermore, each home has been informed and understands that attendance may vary from day to day. At the time of visits LPA toured the facility and observed that the facility was equipped with nine vans and all clients are adequately supervised.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250606135804
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: KAISER BEHAVIORAL CENTER WEST COVINA
FACILITY NUMBER: 198603289
VISIT DATE: 07/07/2025
NARRATIVE
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Based on interviews conducted, records review and 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.

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

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3