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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603452
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:50:47 AM

Substantiated


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
03/03/2022 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220303162000
FACILITY NAME:DHASA CARE IIFACILITY NUMBER:
198603452
ADMINISTRATOR:CARTER, S'HALANAFACILITY TYPE:
735
ADDRESS:757 MILLBURY AVETELEPHONE:
(773) 718-0819
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:4CENSUS: 3DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:S'Halana Carter; AdministratorTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Staff did not treat client with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Sicairos conducted an initial complaint investigation regarding the allegation listed above. LPA met with DSP Noelle Clarke and explained the reason for the visit. Administrator S'Halana Carter arrived shortly thereafter.

The investigation consisted of the following: LPA obtained copies of Client & Staff Rosters. LPA also reviewed Client #1 (C1) file and obtained copies of the following documents: IPP, Physician's Report, and FACE Sheet. LPA interviewed the Administrator, Client #1 (C1), Witness #1, and Staff #1. LPA attempted to interview Client #2 (C2) however C2 is non-verbal. Client #3 (C3) is also non-verbal and was at Day Program during today's visit.

The investigation revealed the following: in regards to the allegation "staff did not treat client with dignity and respect", it is alleged that an unprofessional interaction involving C1 and the Administrator was observed on 03/02/22. The Administrator allegedly used foul language and profanity towards C1. Interaction occured when C1 was being dropped off from the Day Program. (CONTINUED ON 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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 3
Control Number 28-AS-20220303162000
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: DHASA CARE II
FACILITY NUMBER: 198603452
VISIT DATE: 03/10/2022
NARRATIVE
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Interview conducted with Administrator denied this allegation. Administrator indicated alleged interaction involving foul language towards C1 did not happen. Interview conducted with C1 confirmed the allegation to be true. C1 indicated that on 03/02/22, Administrator used foul language towards C1. Phone interview conducted with Witness #1 also confirmed the allegation to be true. Witness #1 was present during the interaction between C1 and Administrator and observed the interaction. Therefore there was sufficient evidence to corroborate with the allegation.

Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview held, and a copy of this report was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20220303162000
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: DHASA CARE II
FACILITY NUMBER: 198603452
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/24/2022
Section Cited
CCR
80072(a)(1)
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(a) Except for children’s residential facilities, 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.

This requirement is not met as evidenced by:
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Licensee/Administrator to ensure facility clients are accorded dignity in their personal relationships with staff and other persons at all times. Personal Rights In-Service training to be conducted with all staff members, Administrator to submit copy of Training Attendance Sheet and copy of Training Agenda by POC due date.
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Based on interviews conducted, it was determined that Administrator spoke to C1 inappropriately (foul language). This poses a potential Health, Safety, and/or Personal Rights risk to the clients in care.
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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: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3