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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603470
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:12:50 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
06/02/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250602160018
FACILITY NAME:SPECIALIZED RESIDENTIAL COVINA BLVD.FACILITY NUMBER:
198603470
ADMINISTRATOR:CARLWAYNE GABLEFACILITY TYPE:
738
ADDRESS:146 SOUTH COVINA BOULEVARDTELEPHONE:
(626) 474-2195
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:4CENSUS: 4DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Carlwayne GableTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff curses at clients in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced initial 10-day Complaint visit to the facility and met with Administrator Carlwayne Gable and explained the purpose of the visit.

The investigation consisted of the following: LPA Nune Margaryan requested and obtained copies of Staff and Clients Roster, obtained copies of C1's Face sheet / Identification and Emergency Information, Preplacement Appraisal Information, Individualized Behavior Support Plan (IBSP), Individualized Program Plan (IPP), 24 hour Head to Toe Assessment. LPA interviewed Administrator, Staff 1 - Staff 3 (S1 - S3), Client 1 - Client 4 (C1 - C4) . S1 was interviewed over the phone.

Continue 9099C




Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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-20250602160018
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: 06/05/2025
NARRATIVE
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The investigation revealed the following: Regarding allegation Staff curses at clients in care. It was alleged that staff member (S1) cursed and used foul language towards the client (C1) because of medications refusal.

Interviewed Administrator and staff denied the allegation. They stated that staff do not curse nor have witnessed anyone use foul language towards C1 or other clients. Administrator and staff interviews revealed that C1 has a history of fabrication. Per RCOC (Regional Center of Orange Country) IPP report and Individualized Behavior Support Plan, C1 has a history of fabricating stories, making accusations towards staff or other clients. Interviewed administrator, S2 and S3 stated they have not heard that S1 curses at C1 or use foul language towards them. Interviewed S1 stated that they never curses client or use foul language towards C1 or other clients when they refuse their medications. Clients interviewed could not corroborate the allegation. Interviewed C1 stated that S1 is nice and S1 or other staff never curse them or use foul language towards them. Interviewed C2, C3 and C4 stated that staff nice and respectful. They didn’t curse and use foul language towards them. They stated that they didn't witness that S1 curses C1 or use foul language toward C1. Interviews show that S1 has not cursed at C1 or use foul language toward C1 or another client. At the time of visit LPA did not observe any staff speak inappropriately to clients in care. LPA was notified that the officer from Industry Sheriff's department was at the facility on 06/04/25 and interviewed C1 and S1 and found no evidence of verbal abuse. Name and badge number of the officer were provided to LPA. Interviews conducted and document reviewed do not corroborate this allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is Unsubstantiated.

An exit interview was conducted and copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2