198603322-3-7-2023-28-AS-RORN-CPSM2H-20230310081332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603322
Report Date: 03/07/2023
Date Signed: 03/07/2023 11:12:30 AM

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
02/07/2023 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230207085716

FACILITY NAME:	HAVEN HOUSE RESIDENTIAL FACILITIES INC		FACILITY NUMBER:	198603322
ADMINISTRATOR:	CAGE, WANDA		FACILITY TYPE:	735
ADDRESS:	757 EDWIN AVE		TELEPHONE:	(909) 436-7423
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	4	CENSUS: 3	DATE:	03/07/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Lindon Johnson and Wanda Cage		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff handled resident in an inappropriate manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Lindon Johnson and discussed the purpose of today's visit.

On 02/16/23, LPA Irra conducted the initial 10-day complaint visit. During this investigation, LPA obtained a copy of the staff and client rosters, interviewed Client #1 (C-1), Client #2 (C-2), Facility Administrator, Staff #1 (S-1) and Staff #2 (S-2). LPA was unable to interview Client #3 (C-3) as C-3 is non-verbal. LPA called Staff #3 (S-3) and was unable to leave a message for a return call. LPA also left messages for San Gabriel Pomona Regional Center (Service Coordinator and Quality Assurance) and C-1's family member for a return call. LPA reviewed C-1's and S-1's through S-3's file and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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-20230207085716

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: HAVEN HOUSE RESIDENTIAL FACILITIES INC	FACILITY NUMBER: 198603322
	VISIT DATE: 03/07/2023

NARRATIVE

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Allegation: Staff handled resident in an inappropriate manner. Staff interviews revealed that on 02/03/23, C-1 came home agitated from C-1’s day program. Per Staff interviews, S-2 was taking C-3 to get C-3’s cell phone repaired and was going to return to the facility to take C-1 out in the community for a walk and C-1 became more upset Staff interviews revealed that S-2 did not grab C-1 (including by the shirt). Per Facility Administrator, she placed S-2 on leave/suspension pending investigation. Per Facility Administrator, San Gabriel Pomona Regional Center (Placement Agency) also conducted an investigation and their finding was unsubstantiated. LPA spoke to San Gabriel Pomona Regional Center and confirmed that the investigation was conducted and the findings were unsubstantiated. (1) out of (2) interviewed Clients indicated S-2 “is rude” and when asked how, the response was “I don’t know” and indicated there has not been any incidents involving S-2. (1) out of (2) interviewed Clients indicated S-2 is “nice”. LPA was unable to interview (1) out of (3) clients due to being non-verbal. LPA attempted to reach C-1’s family member and S-3 and was unsuccessful. Staff and client interviews do not corroborate this 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, copy of report and Appeal Rights were provided to Wanda Cage.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC9099 (FAS) - (06/04)

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