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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603388
Report Date: 07/18/2023
Date Signed: 07/18/2023 01:28:32 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
07/10/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230710111901
FACILITY NAME:WORCHESTER HOMEFACILITY NUMBER:
198603388
ADMINISTRATOR:QUADRI, ABIOLAFACILITY TYPE:
735
ADDRESS:790 WORCHESTER AVETELEPHONE:
(562) 884-4903
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:4CENSUS: 4DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Abiola QuadriTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff hit resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 07/18/23 regarding the above allegations. LPA Ramirez was met by Administrator Abiola Quadri and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 3 interviews(S1 – S3), Client #1 interview (C1 ), Witness #1-2 interviews (W1 – W2), Copies of Client #1 (C1): Face sheet, 30-Day Functional Behavior Assessment and Recommendations for Behavior Intervention Plans dated 10/12/21,Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 3/23/23, Facility/Program Special Incident Report dated 6/3/23, Facility Behavior Data Sheets for June and July 2023, copy of Frank D. Lanterman Regional Center follow-up letter dated 7/16/23 and physical plant tour.

SEE 9099-C for continuation
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
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-20230710111901
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: WORCHESTER HOME
FACILITY NUMBER: 198603388
VISIT DATE: 07/18/2023
NARRATIVE
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The investigation revealed the following: Regarding Allegation: Staff hit resident in care- It is alleged that facility staff hit client in care which resulted in an injury. Three (3) out of three (3) staff interviewed deny this allegation. LPA Ramirez reviewed C1 medical and behavioral file. C1 was admitted into the facility on 8/19/21. Records review revealed C1 has a history of fabricating stories. LPA Ramirez reviewed C1’s Behavior Data Sheets for June and July of 2023. LPA Ramirez reviewed letter from Frank D. Lanterman Regional Center dated 7/16/23, in response to allegation of physical abuse of C1. Inquiry findings conducted by Frank D. Lanterman team on 6/16/23, determined the allegation of physical abuse is unsubstantiated. Interviews with W1 and W2 revealed C1 returned to their day program on 6/5/23. According to W1, staff did not observe or document any injuries to C1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2