198603463-6-20-2023-28-AS-RORN-CVDTD2-20230905143738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603463
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:58:21 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
06/12/2023 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20230612162513

FACILITY NAME:	PEPPERDALE HOME		FACILITY NUMBER:	198603463
ADMINISTRATOR:	SCHAEFER, EVELINA		FACILITY TYPE:	735
ADDRESS:	1923 PEPPERDALE DRIVE		TELEPHONE:	(714) 398-4409
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY:	6	CENSUS: 6	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Evelyn Schaefer		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff spoke inappropriate to resident in care
Staff threaten resident with eviction

INVESTIGATION FINDINGS:

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Licensing Progarm Analyst (LPA) Christine Wong conducted an initial 10 days complaint to address the above allegations. LPA met with caregiver Priscilla Duclayan and allowed the entry of the facility and explained the reason of the visit. Shortly after, the administrator Evelyn Schaefer arrived and assisted with the visit.

The investigation consisted of the following: LPA interviewed administrator, staff#1-#3 (S1-S3) and client#2 and #3 (C2 and C3) in the facility. LPA interviewed Client#1 (C1) at the day program, Client#4 - #6 (C4-C6) via telephone and Staff #4 and #5 (S4 and S5) via telephone. LPA also reviewed C1's file and obtained copy of C1's Individual Personal Plan (IPP) and face sheet.

The investigaiton revealed of the following: Allegation#1 "Staff spoke inappropriate to resident in care." LPA interviewed six clients and five out of six clients denied the allegation and stated that the staff are nice to them and staff never spoke inappropriate to them. They never spoke to them mean or not nicely.
(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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-20230612162513

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: PEPPERDALE HOME	FACILITY NUMBER: 198603463
	VISIT DATE: 06/20/2023

NARRATIVE

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LPA interviewed staff and all denied the allegation and stated that they just tried to work with the client and encouraged them but client was getting agitated and they were the one to speak inappropriately to the staff.

Allegation#2 "Staff threaten resident with eviction" LPA interviewed six (6) client and five out of six clients denied the allegation and said staff never threatened them with eviction. Clients stated that staff talked to them very nicely and they are very encouraging. LPA interviewed staff and all denied the allegation and said they never threatened clients with eviction. They only encouraged and convinced client to take the medication for clients' own good.

Based on LPA's interviews conducted with staff and clients, although, the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

LPA conducted an exit interview with Administrator Evelyn Schaefer and a copy of this report and appeal right were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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