198603452-3-11-2025-28-AS-RORN-DF5LG3-20250326084401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603452
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:29:15 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
09/25/2024 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20240925084645

FACILITY NAME:	DHASA CARE II		FACILITY NUMBER:	198603452
ADMINISTRATOR:	CARTER, S'HALANA		FACILITY TYPE:	735
ADDRESS:	757 MILLBURY AVE		TELEPHONE:	(626) 257-3574
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91746
CAPACITY:	4	CENSUS: 4	DATE:	03/11/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Brandon Hampton		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff pushed a client resulting in a bruise.
Client sustained an unexplained injury.
Staff prevented client from leaving the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to a finding to the above mentioned allegations. LPA met with Brandon Hampton. LPA spoke with Administrator over the phone. Reason for the visit was explained.

The investigation consisted of the following: On 09/26/24 LPA toured the facility and obtained a copy of the Client Roster, Staff Roster. Reviewed C1’s file and obtained copies of relevant documents from C1's file. LPA also interviewed the Administrator, Staff 2, Staff 3 (S2, S3), and Client 1 (C1).

Continue 9099C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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-20240925084645

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: 03/11/2025

NARRATIVE

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Regarding allegations: Staff pushed a client resulting in a bruise. Client sustained an unexplained injury. It was alleged that on 09/19/24 S1 threw C1 to the ground and pushed C1 and C1 has a bruise on the right inner arm.

LPA was not able to interview S1. Administrator stated that S1 was a new hire and was placed on administrative leave because of pending investigation. Administrator informed LPA that S1 was in training as a new staff and always left on shift with Administrator and an experienced staff.

LPA called and left several messages but didn’t hear back from S1. Interviewed Administrator and staff denied the allegations. Administrator stated that on 09/19/24 C1 was upset and had a behavioral episode due to being removed from their room to another one. Administrator indicated that decision to move C1 from their room has been made for safety reason / concerns, and due to cleanliness / hygiene, sanitation. Administrator stated that they discussed with C1 that there have been several safety concerns that C1 is fully aware of as to why the decision has been made to move C1 out of the master bedroom into another location of the home where C1 can be closely monitored because of C1’s behavior. At the time of discussion C1 continued to show signs of aggression by pulling at his hair and screaming. Then C1 ran in their room, shut the door and barricaded thyself in their room, saying was going to hurt thyself. C1 was asked to open the door for safety reasons. C1 said that they will not open the door and told Administrator to go away before they did something stupid. Administrator announced to C1 that S1 and Administrator were coming in C1’s room to assure C1’s safety as C1 continued to push their body behind the door causing complication for staff S1 and Administrator to open the door to assure C1’s safety. As staff was attempting to open C1 door, S1 slid through a big enough crack in the door to gain more momentum as administrator and S1 were able to open the door. Administrator was able to calm C1 down and after about 30 minutes C1 started to talk with Administrator saying, “They understand why they needs to be moved to another room and that they are okay with that”.Administrator stated client possibly caused self infliction and bruises while forcing the right side of their body and arm blocking the entrance of the room to prevent staff from entering. Interviewed S2 stated that C1 was aggressive because of moving to another room. C1 was screaming, yelling at the administrator, stating that not going to move and that no one can tell them what to do. S2 stated that at the time of incident C1 barricaded thyself in the room. S2 looked over to C1’s room and saw Administrator and S1 attempting to open the door.. After a while C1’s mood had lightened, and C1 demeanor was calm. C1 then assisted packing their belongings and switched their room with another client. Continue 9099C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240925084645

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: 03/11/2025

NARRATIVE

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Administrator mentioned that on 09/22/24 received text message from C1’s family member regarding C1 being attacked by S1 resulting bruise on C1 arm from a staff who grabbed C1’s arm. C1’s family member was informed that no one was in the room with C1 besides administrator. Staff didn't enter C1's room. No one touched C1 and that C1 attempted to barricade thyself in the room and threaten to harm thyself as staff assisted in opening C1 door for C1’s safety. Interviewed Administrator and staff stated that they don’t know how C1 got bruises on their arm. Administrator stated that there was no physical contact used at any time during C1’s behavior episode and Administrator was the only one in the room with C1 and S1 and S2 stood at C1’s room as instructed. Interviewed S2 mentioned that on 09/21/24 C1 told to S2 that their arm was sore and asked for ice pack. S2 stated that S2 didn’t noticed any bruises on C1 arm. At the letter time C1 picked up for a home visit and returned on 09/22/24 at night. After returning from home visit C1 showed S2 his arm on which S2 saw a bruise and C1 believed it was received on 09/19/24. Interviewed S4 stated that on 09/19/24 when they started their shift, everything was ok and C1 was calm and started to assist staff to pack C1’s belongings to move to another room. Interviewed S3 stated that they were not at the facility at the time when incident occurred and don’t have any information. Interviewed C1 stated they were notified about switching the room. C1 was told by staff that they need to pack their things throughout the day. C1 was refused to do it and was upset about moving. C1 close the door in their room and tell the staff that they cannot tell C1 what C1 has to do. C1 didn’t follow on Administrator and staff instructions. C1 stated that they don’t like to clean the room saying it is not important. When Administrator and S1 open the door, C1 push S1 and try to close the door. C1 stated that S1 push them back and when C1 was on home visit, noticed bruise on the right inner arm. Per C1’s IPP C1 tends to display aggressive behavior and becoming agitated when C1 does not get their way and a history of becoming upset. Also C1 has a history of physical aggression: making physical threats of or engaging in shoving, pushing, kicking, striking at/or throwing objects at others. Verbal outbursts: raising their voice, screaming. Fabricating stories: Embellishing situations that happened involving other individuals in the home in an effort to get them in trouble. Inappropriate Social Behavior: Isolating himself from others. Noncompliance: Resisting staff directive to complete daily living tasks and / or chores after requested to complete and reminded. On 9/27/24, Industry Sheriff conducted their visit to the facility for their investigation. SIR was provided.

Continue 9099C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20240925084645

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: 03/11/2025

NARRATIVE

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Regarding allegation: Staff prevented client from leaving the facility. It was alleged that C1 had a panic attack and wanted to go outside the facility to get some air, when S1, administrator and another staff blocked the doorway with their bodies to prevent C1 from leaving the room.

Interviewed Administrator, S1 and S2 denied the allegation. Administrator stated that on 09/19/24 C1 was upset do to switching their room and was barricaded thyself in the room and was yelling that was going to hurt thyself. C1 was asked to open the door for safety reason. Administrator and staff were able to open the door and Administrator told staff that the door could now no longer be closed as a response to the safety concern. At the time of incident C1 was having behavioral episodes, raising their voice, pushing the staff. Administrator and interviewed staff stated that no one blocked the doorway and C1 was able to leave the room. Interviewed S1 and S2 stated that they were instructed to stand by the door while Administrator was in C1’s room assisting C1 with packing. They didn’t block the door and C1 was able to leave the room and the facility. Interviewed C1 could not confirm that staff was blocking their doorway. C1 stated that they were upset, but after they were okay and came out from the room and assist staff to packed up their belongings.

Based on statements and interviews conducted with staff, client, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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.

An exit interview was conducted. A copy this report was provided at the time of visit.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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