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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603470
Report Date: 10/05/2021
Date Signed: 10/05/2021 03:09:52 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
09/30/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210930082704
FACILITY NAME:SPECIALIZED RESIDENTIAL COVINA BLVD.FACILITY NUMBER:
198603470
ADMINISTRATOR:POUESI, AGAIOTUPUFACILITY TYPE:
738
ADDRESS:146 SOUTH COVINA BOULEVARDTELEPHONE:
(909) 287-3557
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:4CENSUS: 2DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, AGAIOTUPU POUESITIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff hits residents
Staff threatened resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator, Agaiotupu "Nai" Pouesie who assisted with today's visit.

Regarding the allegation that Staff hits residents, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 - Staff #3, and Resident #1 - Resident #2. LPA also obtained copies of specific documents from Resident #1 and Resident #2 files.

Administrator and Staff interviewed denied the allegation. They stated that staff do not use physical force on the residents. Staff also stated that the facility has cameras in all of the common areas and they have not observed any staff hitting residents. Residents interviewed were unable to corroborate the allegation. Resident #1 and Resident #2 denied that staff have hit them. Regarding the allegation that Staff threatened resident, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 - Staff #3, and Resident #1 - Resident #2. Administrator and staff interviewed denied the allegation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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-20210930082704
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: SPECIALIZED RESIDENTIAL COVINA BLVD.
FACILITY NUMBER: 198603470
VISIT DATE: 10/05/2021
NARRATIVE
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They stated that they staff do not threaten residents, and they have not observed any staff threaten residents. Residents interviewed were unable to corroborate the allegation. Resident #1 stated that a female staff has threatened him, however he did not want to state the staff person's name. LPA observed in Resident file review, that Resident #1 and Resident #2 have a history of making false allegations. Resident #2 denied that staff have threatened him.

Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of the report was provided to Administrator.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2