198603463-11-9-2023-28-AS-DSIS-CZ7UBN-20240105142633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603463
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:33:39 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

COMPLAINT CONTROL NUMBER: 28-AS-20230731160512

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:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Priscilla Duclayan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff used physical force to redirect client, resulting in bruised arms

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***This report supersedes the previous complaint report dated 8/1/2023. The reason it’s being superseded is to issue an immediate civil penalty of $500 due to the substantiated finding of “Staff used physical force to redirect client, resulting in bruised arms”. All findings remain the same. ****

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 health and safety check for the facility. LPA toured the 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 copies 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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 2

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: 11/09/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed 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 to escort C1 back to the facility and C1's bedroom. Staff reported they did the body check the next day and C1 had no bruises. LPA reviewed C1's record and no supportive documents that indicated that staff could put hands on C1 and it should be the last resort.

Based on interviews conducted and recorded 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.

Immediate Civil Penalties in the amount of $500 were issued on today's visit.

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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2