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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603430
Report Date: 07/25/2024
Date Signed: 07/25/2024 11:26:11 AM

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
07/22/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240722215255
FACILITY NAME:GLADSTONE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603430
ADMINISTRATOR:TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:3008 GLADSTONE ST.TELEPHONE:
(909) 392-2973
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:4CENSUS: 4DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Olivia Tomines/S-1 and Jessica Tomines/S-2TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not transport client from day program in a timely manner.
Staff are sleeping during shift.
Clients are utilizing restroom in another client's room.
Facility began alterations prior to notifying Department.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced visit to investigate the above allegations. LPA was allowed entry by Olivia Tomines (S-1) and LPA explained the purpose of today’s visit. Jessica Tomines (S-2) arrived at approximately 8:45 A.M..

During this investigation, LPA obtained a copy of the staff roster, reviewed file for Client #1 (C-1) and obtained relevant information, interviewed Staff #1 (S-1) and Staff #2 (S-2) and interviewed Client #1 (C-1). LPA was unable to interview C-2 as C-2 was asleep during this visit, C-3 was in day program and C-4 is non-verbal.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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 6
Control Number 28-AS-20240722215255
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: GLADSTONE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603430
VISIT DATE: 07/25/2024
NARRATIVE
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Allegation: Staff did not transport client from day program in a timely manner. It was alleged that Mr. Capansana (covering administrator) informed day program staff that he was not able to allocate staff to pick up C-1 (due to client falling earlier at the facility and wanting to return to the facility). Staff interviews revealed that the covering administrator was unable to find staff to allocate to pick up C-1 from day program (on 07/10/24). Per staff interviews, C-1 was dropped off to this facility by the day program at the usual time. C-1 also confirmed the above noted information. Interviews corroborate this allegation.

Allegation: Staff are sleeping during shift. It was alleged that nocturnal staff are sleeping during their shifts. Staff interviews revealed that the night shift staff at times sleep while clients are asleep. Per approved plan of operation (approved by Department of Social Services), “nighttime supervision will consist of awake shift staff overnight coverage (non-live in). Interviews and documentation corroborate this allegation.

Allegation: Clients are utilizing restroom in another client's room. It was alleged there is currently a remodel of the bathroom leaving only one bathroom for all the clients to utilize; this alternate bathroom is C-1’s bedroom. Staff interviews revealed that clients were utilizing the restroom located inside C-1’s bedroom during the remodel of the hallway bathroom. C-1 also confirmed the above noted information. Interviews corroborate this allegation

Allegation: Facility began alterations prior to notifying Department. It was alleged that the hallway bathroom was being remodeled and only the toilet worked and that the Administrator/Licensee did not submit a plan addressing the remodeling (prior to beginning the remodel). Staff interviews revealed that the remodel began 06/28/24 and ended on 07/23/24. Per staff interviews, they confirmed that a notification of this remodel was not sent to the Department until 07/17/24 (via email). Interviews and documentation corroborate this allegation.



Based on LPA's observation and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

California Code of Regulations, title 22 are being cited on the attached LIC 9099D

Exit interview conducted, appeal rights and a copy of this report was provided to Jessica Tomines (S-2).
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20240722215255
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: GLADSTONE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
80065(a)
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Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This standard is not met as evidence by:
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Administrator to review this regulation and provide a written statement as to how this facility will remain in compliance and submit to LPA Irra by POC due date.
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Staff interviews revealed that the covering administrator was unable to find staff to allocate to pick up C-1 from day program (on 07/10/24). Per staff interviews, C-1 was dropped off to this facility by the day program at the usual time.
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Type B
07/29/2024
Section Cited
CCR
85065.6(g)
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Night Supervision (g) In facilities providing care to Regional Center clients who rely upon others to perform all activities of daily living, night supervision shall be maintained as required by the Regional Center, but no less than the staff-client ratio specified in Sections 85065.6(f) and (f)(1).
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Administrator to review this regulation and provide a written statement as to how this facility will remain in compliance and submit to LPA Irra by POC due date.
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This standard is not met as evidence by:

Staff interviews revealed that the night shift staff at times sleep while clients are asleep.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20240722215255
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: GLADSTONE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
85087(a)(4)
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Buildings and Grounds (a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements: (4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.
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Administrator to review this regulation and provide a written statement as to how this facility will remain in compliance and submit to LPA Irra by POC due date.
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This standard is not met at evidence by:

Staff interviews revealed that clients were utilizing the restroom located inside C-1’s bedroom during the remodel of the hallway bathroom.
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Type B
07/29/2024
Section Cited
CCR
80086(a)
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Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
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Administrator to review this regulation and provide a written statement as to how this facility will remain in compliance and submit to LPA Irra by POC due date.
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This standard is not met as evidenced by:

Staff interviews revealed that the remodel began 06/28/24 and ended on 07/23/24. Per staff interviews, they confirmed that a notification of this remodel was not sent to the Department until 07/17/24 (via email).
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
07/22/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240722215255

FACILITY NAME:GLADSTONE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603430
ADMINISTRATOR:TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:3008 GLADSTONE ST.TELEPHONE:
(909) 392-2973
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:4CENSUS: 4DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Olivia Tomines/S-1 and Jessica Tomines/S-2TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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2
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Client sustained injury while in care due to staff neglect.
Uncleared adult.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced visit to investigate the above allegations. LPA was allowed entry by Olivia Tomines (S-1) and LPA explained the purpose of today’s visit. Jessica Tomines (S-2) arrived at approximately 8:45 A.M..

During this investigation, LPA obtained a copy of the staff roster, reviewed file for Client #1 (C-1) and obtained relevant information, interviewed Staff #1 (S-1) and Staff #2 (S-2) and interviewed Client #1 (C-1). LPA was unable to interview C-2 as C-2 was asleep during this visit, C-3 was in day program and C-4 is non-verbal.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20240722215255
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: GLADSTONE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603430
VISIT DATE: 07/25/2024
NARRATIVE
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Allegation: Client sustained injury while in care due to staff neglect. It was alleged that on 07/10/2024, C-1 began to complain of C-1’s knee hurting while at day program. C-1 had an abrasion that was bleeding and there was light bruising and swelling to the right knee. C-1 disclosed that C-1 fell off a chair while waiting for the bus outside of facility. Staff interviews revealed that C-1 likes to wait outside this facility (near front entrance) sitting on the chair waiting for day program staff to pick C-1 up every day. Interviewed staff indicated that on 07/10/24, while C-1 was sitting on the chair, the chair bent causing C-1 to be lowered to the ground (not fall) and caused C-1 to utilize C-1’s knees and staff assistance to stand up. Per staff interviews, C-1 was assisted and checked with no concerns noted (no bleeding, bruising nor swelling). Per staff interviews, C-1 requested to attend day program the same day. C-1 also confirmed the above noted information. Interviews do not corroborate this allegation.

Allegation: Uncleared adult. It was alleged that Licensee’s relative was the individual remodeling the restroom and that individual did not have fingerprint clearance. It was also alleged that this same individual was present when C-1 fell off the chair. Staff interviews revealed that the individual remodeling is not left alone with clients and that there is always staff present. Per staff interviews, the individual remodeling does not provide direct care to clients. Interviews do not corroborate this allegation.

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



Exit interview conducted, a copy of the Appeal Rights and this report was provided to Jessica Tomines (S-2).
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6