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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603373
Report Date: 04/10/2023
Date Signed: 04/10/2023 05:27:48 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
04/03/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230403152123
FACILITY NAME:RISING HILL DEVELOPMENTAL HOME IIFACILITY NUMBER:
198603373
ADMINISTRATOR:BOULINGLY, PAMELAFACILITY TYPE:
735
ADDRESS:4739 N. EDENFIELD AVETELEPHONE:
(562) 508-2007
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:4CENSUS: 4DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pamela Bouligny, administratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident not accorded dignity in relationships with staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met Pamela Bouligny, administrator. LPA explained the purpose of today's visit.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #5 (S5); interviews of clients from client#1 (C1) through client #4 (C4); reviewed client#1’s record reviews, and a facility tour. LPA obtained copies of the staff and client rosters, client#1’s files and documents with relevant information.

In regard of the allegation, “resident not accorded dignity in relationships with staff," it was alleged that staff#1 (S1) was being mean and making fun of client#1 (C1) because staff said C1 has to change bed sheets every night.

(-continued in LIC 9099 C-)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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 2
Control Number 28-AS-20230403152123
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: RISING HILL DEVELOPMENTAL HOME II
FACILITY NUMBER: 198603373
VISIT DATE: 04/10/2023
NARRATIVE
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 The investigation revealed the following:
Per client interviews, Client#1 (C1) stated C1 would get mad when staff said things about changing C1’s bed sheets. Three (3) out of four (4) clients interviewed could not corroborate the allegation. Client interviews revealed staff did not make fun or been mean to client. All five (5) staff who were interviewed denied the allegation. Staff interviews revealed facility had a zero tolerance policy on staff degraded clients and provided in service training to ensure clients’ right. Administrator took staff#1 (S1) off work schedule after regional center made administrator aware of this allegation. Administrator had put S1 on training program again to ensure S1 would re-equipped when resume to work. Therefore, there is not preponderance evidence to prove the facility staff did not keep a dignity relationship with clients.

Based on the information obtained during the investigation, interviews with staff, clients, review of client files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted and finding were discussed. A copy this report was provided to Pamela, administrator at time of visit.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
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