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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603403
Report Date: 11/17/2021
Date Signed: 11/17/2021 04:36:55 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
10/08/2021 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211008112611
FACILITY NAME:TOMINES ADULT RESIDENTIAL FACILITY IIFACILITY NUMBER:
198603403
ADMINISTRATOR:TOMINES, JONATHANFACILITY TYPE:
735
ADDRESS:613 KATHERINE DR.TELEPHONE:
(323) 246-4059
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY:4CENSUS: 2DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff Angelito SantosTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff member did not treat resident with dignity and respect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff Angelito Santos.
The purpose of the visit is to investigate the above allegation and deliver findings.
At today's visit 11/17/2021 Client 1 and 2 was interviewed from 2:00 P.M. to 3:00 P.M. Client 1 could not elaborate on any details regarding the allegation and did not want to continue to be interviewed.
At initial visit 10/12/2021 the following occurred: from 2:30 to 3:00 P.M. interviews were conducted with Staff S1 and S 2.
Interview was conducted with Assistant Administrator from 3:30 to 3:50.
Attempt was made to interview Client C 1 who refused to be interviewed.
In regards to the allegation Facility staff member did not treat resident with dignity and respect based on interviews conducted with staff, clients, Social Worker for Client 1, family member of Client 1 and information gathered it was revealed in Initial Program Plan (IPP) dated 11/23/2020 that Client 1 has a history of maladaptive behaviors which include verbal aggression, self abuse, AWOL, non-compliance, temper tantrums,

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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 2
Control Number 28-AS-20211008112611
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: TOMINES ADULT RESIDENTIAL FACILITY II
FACILITY NUMBER: 198603403
VISIT DATE: 11/17/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
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14
15
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and fabrication of stories.
Interview with Social Worker for family 1 who stated that Client 1 has a history of fabricating stories and had met staff and didn't see any malice. Said Client 1 has several behaviors and has hallucinations and is delusional.
Interview with family member of Client 1 who said she is not in stable mental condition and tends to make up stories. Said that she has been in close contact with all staff every day and has not seen anything unprofessional. The day of the allegations she was there and said Client 1 was very off . Very unstable and making up stories.
Interviews with staff who stated that Client 1 has a history of fabrications and had changed medication and it didn't work.
Staff stated that their cell phones are on counters and that they work in pairs and nothing inappropriate has been observed or spoken.
Client interviewed stated that staff act appropriately to clients and has not observed any wrong doing. Stated that he has not seen staff with cell phones out and never observed any staff showing inappropriate material on their phone.
Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2