<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603368
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:43:31 PM

Substantiated


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
09/14/2021 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210914132126
FACILITY NAME:FOXDALE HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603368
ADMINISTRATOR:TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:540 N. FOXDALE AVETELEPHONE:
(909) 306-4692
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:4CENSUS: 3DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Olivia Tomines; AdministratorTIME COMPLETED:
02:58 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to treat clients with respect and dignity.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above allegation. LPA met with DSP Mary Joe Ongbico and explained the reason for the visit. Administrator Olivia Tomines arrived shortly thereafter.

The investigation consisted of the following: LPA obtained copies of Client & Staff Rosters. LPA reviewed Client #1 (C1) file and obtained copies of FACE Sheet, IPP, and Physician's Report. LPA also conducted interviews with Administrator, Staff #2 (S2), and Client #1 - Client #3. Staff #1 (S1) could not be interviewed as S1 was terminated from her position on 09/13/21. C1's Service Coordinator was also interviewed over the phone.

The investigation revealed the following: in regards to the allegation "staff failed to treat clients with respect and dignity", it is alleged that S1 would "constantly provoke" C1. C1 was allegedly told by S1 that she didn't like him and that other staff members didn't like him either. (CONTINUED ON 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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-20210914132126
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: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368
VISIT DATE: 09/16/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews with Administrator and S2 revealed that they did not observe S1 being disrespectful to C1 or any of the clients at the home. Administrator and S2 indicated that they treat all the clients with respect and dignity. 3 out 3 clients interviewed revealed that they felt that S1 was disrespectful towards them. Clients interviewed indicated that S1 was mean and they did not like her tone of voice. All 3 clients interviewed indicated that they are much happier now that S1 is not working at the facility. San Gabriel/Pomona Regional Center's Quality Assurance Department closed out this incident since S1 was terminated and there were no other concerns reported. Administrator began re-training staff on Abuse/Neglect & Clients Rights on 09/15/21.

Based on LPA's observations and interviews which were conducted and record review, 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 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview held, and a copy of this report was provided along with appeal rights.


NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210914132126
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: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator to ensure that clients are all accorded dignity in his/her personal relationships with staff and other persons at all times. Administrator to conduct in-service Personal Rights training with all staff members and submit sign in sheet of staff members who attended training by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted with all 3 clients, it was revealed that S1 did not accord clients with dignity and respect. This poses a potential health,safety, and/or personal rights risk to the 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: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3