198603474-9-14-2022-28-AS-RORN-CKBKWK-20221018081601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603474
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:30:21 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
02/07/2022 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220207161024

FACILITY NAME:	HELIO		FACILITY NUMBER:	198603474
ADMINISTRATOR:	MARCELO, TAJ		FACILITY TYPE:	735
ADDRESS:	510 FOXPARK DRIVE		TELEPHONE:	(929) 429-0836
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	4	CENSUS: 4	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Connie Mitchell		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Client sustained an injury while in care.
Staff did not seek medical attention for client in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Connie Mitchell and disussed the purpose of today's visit.

The initial investigation visit was conducted on 02/09/2022. During the course of this investigation, LPA obtained a copy of the Client Roster, a copy of the Staff Roster, interviewed the Facility Administrator, Staff #1 (S-1), Client #1 through Client #3 (C-1 and C-3). LPA was unable to interview Client #4 (C-1) as C-4 was unable to undertand the interview questions. LPA also reviewed C-1's file and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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-20220207161024

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: HELIO	FACILITY NUMBER: 198603474
	VISIT DATE: 09/14/2022

NARRATIVE

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Allegation: Client sustained an injury while in care. Staff interviews revealed that C-1 exhibits self injurious behaviors which include C-1 hitting C-1’s head on the wall. Staff interviews revealed C-1 has a behavioral plan which includes intervention on C-1’s self injurious behavior (staff implement and report to C-1’s behaviorist). Per staff interviews, staff maintain documentation on C-1’s behavior. LPA obtained relevant documentation from C-1’s file. Per staff interviews, C-1 had a self injurious behavior on 02/02/22 involving C-1’s hitting C-1’s head on the wall. (1) out of (4) client interviews revealed that C-1 exhibits self injurious behaviors when upset and when this occurs staff intervene. (2) out of (4) client interviews did not recall incidents of C-1’s self injurious behavior (hitting head on wall). (1) out of (4) interviewed clients was unable to understand the interview questions.

Allegation: Staff did not seek medical attention for client in a timely manner. Staff interviews revealed that on 02/02/22, C-1 received a consultation by C-1’s physician and staff were ordered to monitor for concussion symptoms. Per staff interviews, C-1 was not ordered to be taken to the Emergency Room for further evaluation. C-1 was ordered to rest for the remaining of the day and resume regular activity the next day. Per staff interviews, C-1 has had blurry vision and burning eyes prior to this incident and C-1’s physician is aware of this matter. However, when C-1 was interviewed, C-1 indicated C-1 is not experiencing blurry vision and burning eyes. (3) out of (4) interviewed clients indicated the staff seek medical attention for clients on a timely manner. (1) out of (4) interviewed clients was unable to understand the interview questions.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated

Exit interview was conducted and a copy of this report and appeal rights were provided to Connie Mitchell.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

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