198603373-7-21-2023-28-AS-DSIS-CU2TYQ-20230724150906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603373
Report Date: 07/21/2023
Date Signed: 07/21/2023 04:49:44 PM

Substantiated

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
06/28/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230628085459

FACILITY NAME:	RISING HILL DEVELOPMENTAL HOME II		FACILITY NUMBER:	198603373
ADMINISTRATOR:	PAMELA BOULIGNY		FACILITY TYPE:	735
ADDRESS:	4739 N. EDENFIELD AVE		TELEPHONE:	(562) 508-2007
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	4	CENSUS: 4	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Jennifer Oglesby - Licensee/Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff member inappropriately handled residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Andre Hearn, Direct Support Professional I (DSP I) and explained the reason for the visit. LPA spoke with Jennifer Oglesby, Licensee/Administrator and stated she will be coming over to the facility to assist.

During the initial complaint investigation conducted on 7/03/2023, LPA obtained copies of client & staff rosters, C1-C3 records such as: incident reports (dated 6/26/2023 & 6/27/2023), San Gabriel/Pomona Regional Center IPPs (dated 3/29/2023) and Medical/Specialist Visit Information (4/24/2023, 4/28/2023 & 5/09/2023). LPA interviewed the Administrator and Staff #1 (S1). Unable to interview the clients as (3) clients were in the Day Program and (1) client was out of state visiting family. LPA requested copies of the Staff Personal Rights training.

During today’s visit, Licensing Program Analyst (LPA) Bennette Pena toured the facility' common areas and obtained updated copies of client & staff rosters, Staff Personal Rights training and C4’s Placement Information and Medical/Specialist Visit Information. LPA also obtained copies of C1-C3's Placement Information. LPA Pena interviewed Staff #3 (S3) and Client #1 (C1)-Client #4 (C4). On 7/13/2023, LPA Pena telephonically interviewed Staff #2 (S2). ***CONTINUED ON LIC9099-C***

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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-20230628085459

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: RISING HILL DEVELOPMENTAL HOME II	FACILITY NUMBER: 198603373
	VISIT DATE: 07/21/2023

NARRATIVE

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The investigation consisted of the following: Regarding allegation: “Staff member inappropriately handled residents in care.” It is alleged that a staff put clients in a headlock and gave them a noogie on top of their heads, sat on them, and wrestled them on the floor. Interview conducted with the Licensee revealed that she was unaware of the incident until it was reported during the review meeting with SGPRC. Licensee questioned and suspended S2 after admitting the incident to be true. S1 confirmed the allegation and stated that she witnessed the incident happened twice. S1 indicated that she tried to intervene and told S2 to stop. S2 confirmed the allegation and stated that the incident happened twice but could not remember the exact dates. S2 stated that she was horseplaying with the clients with the intention of keeping them happy. S2 also indicated that no one sustained injury during the incidents. S3 stated that he did not witness the alleged incident. C1-C3 confirmed the allegation and stated that no one got hurt. C4 stated that she did not participate while the others were playing around. Interview conducted with W1 indicated that SGPRC is aware of the incident and being reviewed at this time.

Based on interviews and information obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Licensee, Jennifer Oglesby along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230628085459

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: RISING HILL DEVELOPMENTAL HOME II	FACILITY NUMBER: 198603373
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/28/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Rights...(a) Except... 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	1 2 3 4 5 6 7	Licensee shall re-train and conduct a staff in-service training on Personal Rights, Zero Tolerance to ensure that the personal rights of clients are not violated. Licensee will submit a copy of the training along with the topics discussed, sign-in sheets with staff names and signatures, date, time/duration of training and name of the presenter for this training to CCL/LPA by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews conducted with staff and clients, the licensee did not comply with the section cited above in which S2 inappropriately handled clients while rough playing which poses a potential health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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