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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603477
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:56:57 PM

Document Has Been Signed on 10/19/2023 01:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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:JRC TITANIUM CARE HOME INC.FACILITY NUMBER:
198603477
ADMINISTRATOR:CANONES, RONELFACILITY TYPE:
735
ADDRESS:212 E LA VERNE AVETELEPHONE:
(909) 279-5485
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
10/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Amber Torres, DSPTIME COMPLETED:
02:10 PM
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 Licensing Program Analyst (LPA) Cynthia Chan conducted a case management to issue a deficiency in response to the complaint #28-AS-20230602135820. LPA met with Staff, Amber Torres and explained the reason for this visit.

During the complaint investigation, it was determined that Staff #1 (S1) did not utilize appropriate CPI behavior intervention techniques while handling Client #1 (C1). On 6/1/23, C1 became aggressive towards S1 and physically attacked staff. S1 acknowledged biting C1 in self-defense in order to escape from client. LPA obtained a copy of the San Gabriel/Pomona Regional Center Corrective Action Plan (CAP) and it indicated that S1 bit C1 in order for C1 to release his/her grip of staff’s hair. In addition, the CAP noted that “Biting a resident is not authorized or permissible intervention in the utilization of the CPI behavior intervention technique.” Therefore, it is determined S1 failed to utilize the instructional methods which are specified in the facility’s program design.

A deficiency is being issued today. An exit interview was held and a copy of this report along with appeal rights were given to Ms. Torres.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 01:56 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 10/19/2023 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JRC TITANIUM CARE HOME INC.
FACILITY NUMBER: 198603477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited
CCR
80065(a)

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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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The licensee shall conduct an in-service training with staff to ensure proper use of CPI techniques in handling challenging behaviors. The log shall be submitted to LPA by due date 10/26/23.
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Based on documentation, staff did not utilize appropriate CPI techniques to handle client which poses a potential health, safety, and personal rights to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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