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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603463
Report Date: 08/01/2023
Date Signed: 08/01/2023 02:13:04 PM

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
07/31/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230731160512
FACILITY NAME:PEPPERDALE HOMEFACILITY NUMBER:
198603463
ADMINISTRATOR:SCHAEFER, EVELINAFACILITY TYPE:
735
ADDRESS:1923 PEPPERDALE DRIVETELEPHONE:
(714) 398-4409
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:6CENSUS: 6DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Evenlyn Schafer TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff used physical force to redirect client, resulting in bruised arms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted the 24 hours health and safety check for the facility and met with Staff Priscilla Duclayan and explained the reason of the visit and Shortly after, the administrator Evelina Schafer arrived and assisted with the visit.

The investigation consisted of the following: LPA conducted a healthy and safety check for the facility. LPA toured thef facility. Sufficient food supplies of 2 day perishable and a week of non-perishable were observed. There are no immediate health and safety concerns observed at this time. LPA interviewed the administrator, staff (S2) and one client (C2) in the facility and three staff (S1, S3 and S4), five clients (C1, C3-C6) via telephone. LPA also obtained copied of the documents for C1.

(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 5
Control Number 28-AS-20230731160512
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: 08/01/2023
NARRATIVE
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The investigation revealed of the following: Allegation "Staff used physical force to redirect client, resulting in bruised arms" LPA interviewed clients and reported they never seen any staff rough on clients. Client reported staff was only grabbing the client to the bedroom. LPA interviewed the staff and stated C1 was yelling and screaming loud by the side of the facility and staff was convinced C1 to come inside the facility but C1 denied and staff did not want C1 to get hurt by the trash bin outside the facility, therefore staff grabbed C1's armpit probably to escort C1 back to the facility and C1's bedroom. Staff reported they did the body check next day and C1 had no bruises. LPA reviewed C1's record and no supportive documents that indicated that staff can put hands on C1 and it should be the last resort.

Based on interviews conducted and record reviewed, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, are being cited on attached LIC9099D.

Exit interview was conducted with Facility Administrator Evelyn Schafer, A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/31/2023 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20230731160512

FACILITY NAME:PEPPERDALE HOMEFACILITY NUMBER:
198603463
ADMINISTRATOR:SCHAEFER, EVELINAFACILITY TYPE:
735
ADDRESS:1923 PEPPERDALE DRIVETELEPHONE:
(714) 398-4409
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:6CENSUS: 6DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Evenlyn Schafer TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff forced a client to take out the trash.
Staff are denying client from seeing their significant other.
Client does not feel safe with facility staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted the 24 hours health and safety check for the facility and met with Staff Priscilla Duclayan and explained the reason of the visit and Shortly after, the administrator Evelina Schafer arrived and assisted with the visit.

The investigation consisted of the following: LPA conducted a healthy and safety check for the facility. LPA toured thef facility. Sufficient food supplies of 2 day perishable and a week of non-perishable were observed. There are no immediate health and safety concerns observed at this time. LPA interviewed the administrator, staff (S2) and one client (C2) in the facility and three staff (S1, S3 and S4), five clients (C1, C3-C6) via telephone. LPA also obtained copied of the documents for C1.

(See LIC 9099C 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: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230731160512
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: 08/01/2023
NARRATIVE
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The investigation revealed of the following : Allegation#1 "Staff forced a client to take out the trash." LPA interviewed six clients, four out of six clients denied the allegation and reported staff never forced them to take out the trash. They usually do it on their own. LPA interviewed staff and denied the allegation and reported they never forced client to take out the trash. It's only voluntary. If client wants to help, they would let them help out the house chores but if they do not want it, it's okay, they would never forced them to do it.

Allegation#2 "Staff are denying client from seeing their significant other." LPA interviewed six clients and five out of six clients denied the allegation and reported staff never denied them seeing their families or friends. Staff would schedule them to see their significant others. LPA interview staff and denied the allegation and reported it's clients right and would never deny them to see their significant others. They would ask client to tell them ahead and facility can plan ahead and they would take them to see their family or friends. Administrator reported C1 was upset due to C1's boyfriend was rescheduled the meet up this coming Saturday and C1 was getting agitated.

Allegation#3 "Client does not feel safe with facility staff." LPA interviewed six clients and five out of six clients denied the allegation and reported they all feel safe living in the facility. All staff are nice to them and they have no issues living in the facility. LPA interviewed staff and reported they all have a good relationship with clients and only sometimes client were having behaviors and they were not able to redirect them.

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: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230731160512
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
08/15/2023
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3)(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature,
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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The requirement was not met as evidenced by staff and client interviewing, there's no supportive docuemnts stated that staff can put hands on client and S1 was grabbed C1's armpit to escort back to the facility and C1's room which posed a potential risk to 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5