198603463-12-7-2023-28-AS-DSIS-CZ7UBM-20240105142633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603463
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:56:06 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 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:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Van Nguyen		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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**This report supersedes reports dated 11/09/23 and 08/01/23. Report 11/09/23 is being superseded as LIC 9099D was not attached to the substantiated report. Report 08/01/23 is being superseded as it did not include the immediate $500 civil penalty in relation to the substantiated findings of “staff used physical force to redirect client resulting in bruised arms”. Grammatical errors are also being corrected on the reports. 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. (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: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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-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: 12/07/2023

NARRATIVE

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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.

The investigation revealed the following: Allegation "Staff used physical force to redirect client, resulting in bruised arms" LPA interviewed clients and five out of six clients reported they have never seen any staff handle clients in a rough manner. A client reported observing staff redirecting C1 to the bathroom by grabbing C1 by the arms. LPA interviewed the staff and stated C1 was yelling and screaming loudly by the side of the facility and staff was attempting to convince C1 to come inside the facility but C1 refused. Staff did not want C1 to get hurt as C1 was standing by the trash dumpster outside of the facility, therefore staff#1 grabbed C1 by the armpit in order to escort and redirect C1 back to the facility and C1's bedroom. Staff reported they did a body check of C1 the next day and C1 had no bruises. LPA reviewed C1's record and did not observe supportive documents that indicated that staff could put their hands on C1 in order to redirect them.

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 DSP Van Nguyen, 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: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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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: 12/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/14/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	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,	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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