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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603322
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:30:00 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
06/20/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230620135336
FACILITY NAME:HAVEN HOUSE RESIDENTIAL FACILITIES INCFACILITY NUMBER:
198603322
ADMINISTRATOR:CAGE, WANDAFACILITY TYPE:
735
ADDRESS:757 EDWIN AVETELEPHONE:
(909) 436-7423
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:4CENSUS: 2DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Horace Martin (S-1)TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Client lost severe weight while in care.
Staff failed to seek medical attention for client.
Staff locked client in his room.
Staff failed to meet client's needs.
Staff refused to provide medical records to client's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit for the above allegations. LPA met with Horace Martin/S-1 and discussed the purpose of today’s visit.

On 06/29/23, Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit. LPA met with Wanda Cage and discussed the purpose of this visit. During this visit, LPA obtained a copy of the Client and Staff rosters and reviewed Client #1's (C-1) file and obtained relevant documentation. LPA was unable to interview C-1 as C-1 no longer resides at this facility. C-2 and C-3 were not home during this visit. LPA interviewed Facility Administrator. LPA called and left a message for a return call for placement agency, San Gabriel Pomona Regional Center.

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: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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-20230620135336
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: 07/11/2024
NARRATIVE
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During the course of this investigation, LPA also interviewed Staff #1 (S-1) through Staff #3 (S-3). LPA left a message for Staff #4 (S-4) for a return call. LPA attempted to interview Client #2 (C-2) and Client #3 (C-3) and was unsuccessful as both were not able to understand interview questions and/or are non-verbal.

Allegation: Client lost severe weight while in care. It was alleged that C-1 had lost weight during his stay at this facility. Staff interviews revealed that C-1's medical professional was informed of C-1's weight loss. Per staff interviews, C-1 consulted with the medical professional on a consistent basis (weight was being monitored by the medical professional). LPA observed medical documentation on file for C-1 regarding C-1’s weight. Interviews and record review do not corroborate this allegation.

Allegation: Staff failed to seek medical attention for client. It was alleged that C-1 had a fungus on hands and feet that was not being treated. Staff interviews revealed that C-1 did not have fungus on their hands nor feet. Interviewed staff indicated C-1 consulted with their physicians (including podiatrist) on a consistent basis. C-1’s medical records were reviewed and there was no indication of C-1 having fungus on their hand nor feet. Interviews and record review do not corroborate this allegation.

Allegation: Staff locked client in his room. It was alleged that C-1 was locked in their room when C-1 had a behavior. Staff interviews revealed that there are no rooms that have locks. Staff interviews revealed that clients are not locked in their room. Staff interviews revealed that when C-1 was upset, staff would ask C-1 to go to their room “to cool off” and did not lock C-1 in their room. LPA toured facility and did not observe any locks on bedroom doors. Interviewed staff indicated that they have not received any concerns/complaints pertaining to this matter. Interviews and tour do not corroborate this allegation.

Allegation: Staff failed to meet client's needs. It was alleged that clients in this home are not attending any outings. It was also alleged that C-1 was wearing a wrong shoe size and C-1 did not have clothes that were appropriate to wear. Staff interviews revealed that clients are taken out for outings consistently. Staff interviews revealed that clients are taken to church functions, local shopping centers, local restaurants, movies, bowling, parties, ect.. Interviewed staff also indicated that C-1 wore appropriate clothing and shoes that fit. Interviewed staff indicated that they have not received any concerns/complaints pertaining to these matters. Interviews do not corroborate this allegation.

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

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230620135336
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: 07/11/2024
NARRATIVE
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Allegation: Staff refused to provide medical records to client's authorized representative. It was alleged that medical records were requested and the requestor was told that the facility did not have records. Staff interviews revealed that the Facility Administrator is responsible for medical records requests. Per S-1/Facility Administrator, C-1 is not conserved. S-1/Facility Administrator indicated she received a verbal request from C-1's family member for C-1's medical records on 06/16/23 (date C-1 moved out) and did not receive any requests prior to this date. S-1/Facility Administrator indicated she sent a copy of C-1's medical records to San Gabriel Pomona Regional Center. Interviews do not corroborate this allegation.

Based on record review and interviews conducted the findings indicate, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



An exit interview conducted, appeal rights and a copy of this report was provided Horace Martin/S-1.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3