198603368-4-14-2025-28-AS-WSHO-DFURQ3-20250418131250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603368
Report Date: 04/14/2025
Date Signed: 04/14/2025 09:57:33 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/22/2025 and conducted by Evaluator Mayra Cota

COMPLAINT CONTROL NUMBER: 28-AS-20250222171306

FACILITY NAME:	FOXDALE HOME ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198603368
ADMINISTRATOR:	TOMINES, OLIVIA		FACILITY TYPE:	735
ADDRESS:	540 N. FOXDALE AVE		TELEPHONE:	(626) 337-7782
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	4	CENSUS: 4	DATE:	04/14/2025
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Olivia Tomines, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not prevent an altercation between residents resulting in a resident’s injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA Cota met with Olivia Tomines, Administrator and discussed the purpose of the visit.

The investigation consisted of the following:
On 3/4/25, LPAs Cota and Gonzalez, toured the facility, obtained copies of client and staff rosters, reviewed files for Clients 1-4 (C1-C4), obtained copies of Face Sheets, Progress Report for Behavioral Services and Individual Program Plans (IPPs) for C1 and C2, and Referral Summary from San Gabriel/Pomona Regional Center for C1. Copies were also obtained of incidental notes from January - March 2025 for C2, and CPI Crisis Intervention Certificates for Staff 1-5. LPAs conducted interviews with Staff 1, 2 and 4 and telephonically with Staff 3. C1 and C3 were also interviewed during visit. Interview with Regional Center Service Coordinator (RC) was conducted telephonically on 3/4/25. LPAs also attempted to interview C2, however, C2 did not want to speak to LPAs during time of visit. Interview was also attempted with C4, however, C4 was non-responsive to questions asked by LPAs. ****Report continues on LIC 9099-C

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

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-20250222171306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOXDALE HOME ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198603368
	VISIT DATE: 04/14/2025

NARRATIVE

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Regarding: Staff did not prevent an altercation between residents resulting in resident’s injury.

It is alleged, facility staff did not adequately protect client from being hit by a peer during altercation after client had expressed fear due to being threatened and called racial slurs by peer. It is also alleged, client had asked staff to intervene but instead of addressing the issue, staff advised client to “ignore.”

The investigation revealed the following:

Interviews with four out of four staff (S1-S4) revealed, client came to them initially with concerns regarding peer calling C1 racial slurs. S1-S4 stated, they advised C1 to ignore peer when peer was exhibiting that type of behavior towards C1. Further interviews with S1-S4 revealed, they had heard peer using racial slurs like the N-word and other bad names toward C1, however, they addressed the incidents by continuing to advise C1 to ignore peer and stay away from them. Regarding the physical altercation which took place on 2/15/2025, S1-S4 stated, peer grabbed C1 by their shirt and proceeded to physically attack C1 after staff heard peer calling C1 bad names.

Interviews with clients revealed peer had been using racial slurs like the N-word days before the physical altercation ensued. Interviews also revealed, staff were made aware before the altercation that peer’s behavior toward client was concerning and scared and made them feel unsafe. However, staff advised client to ignore and stay away from peer during the incidents.

Record review indicated, staff did not intervene appropriately by implementing peer’s Individual Program Planning and Behavior Treatment Plan regarding reducing physical aggression, using proper ways to communicate and maintaining boundaries, before the physical altercation ensued.

Based on statements gathered from staff and clients 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) cited on the attached 9099-D.

Exit interview conducted with Olivia Tomines, Administrator. Copy of the report and Appeal Rights provided at the time of visit.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250222171306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 04/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/29/2025 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Rights (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 if his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit to LPA by the POC due date a behavioral plan addressing implementation of behavior strategies and supervision of client in care. Plan will be also be submitted to Regional Center.
	8 9 10 11 12 13 14	Based on interviews conducted and record review, licensee did not prevent an altercation between residents from happening when staff did not apporopriately address concerns from client when peer made them feel scared and unsafe.	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: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025

LIC9099 (FAS) - (06/04)

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