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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603489
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:11:39 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
03/13/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240313153950
FACILITY NAME:ABOVE AND BEYOND ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603489
ADMINISTRATOR:SAUNDERS, TONYAFACILITY TYPE:
735
ADDRESS:430 S. MOUNTAINTELEPHONE:
(951) 323-3852
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:4CENSUS: 4DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Terri AustinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff withheld residents' personal belongings
Facility doesn't have a working telephone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 03/15/2024 and delivered findings. LPA Ramirez was met by Direct Support Staff (DSP) Terri Austin and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster, Client Roster (LIC 9020), Staff #1-4 interviews (S1-S4 ), interview of Clients#1 (C1), attempted interview of Clients#2-4 (C2-C4), interview of Witness#1 (W1), review of clients#1-4 client records, copies of clients #1,2,3 (C1- C3) Physician’s report, face sheet, Client daily progress notes, Unusual Incident Reports (LIC 624), Admission Agreement, Individual Program Plan (IPP), and other pertinent documents and physical plant tour.

SEE 9099- for continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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 3
Control Number 28-AS-20240313153950
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: ABOVE AND BEYOND ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603489
VISIT DATE: 03/15/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff withheld clients' personal belongings- It is alleged S1 withheld C1’s headphones and the remote controller to the T.V. in C1’s shared bedroom. LPA Ramirez reviewed San Gabriel/Pomona Regional Center (SGPRC) Corrective Action Plan (CAP) dated 3/12/24. The CAP revealed that S1 confirmed that they have in the past removed C1’s headphones and the remote controller to C1’s T.V. due to C1 increasing the volume after being repeatedly told by staff to lower the volume. S1 additionally revealed that they would search for C1’s headphones and the T.V. remote control in C1’s room and would request these items from C1 in the afternoon when S1 discovered the afternoon shift did not remove these items from C1. Interview with W1 revealed that facility staff were aware that C1 had these items removed and that staff acknowledged this was done to so C1 would sleep at night, to prevent C1 from increasing the T.V. volume too loud which causes his roommate (C2) to have behaviors. LPA Ramirez interviewed C1 and C1 confirmed this allegation and stated it made C1 upset when staff took these items away. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Facility doesn't have a working telephone- It is alleged on 3/5/24, the facility telephone was in disrepair. The CAP revealed that the facility phone was observed to not be working on 3/5/24 and was replaced and repaired within two hours. An interview with W1 confirmed this allegation. Three (3) out of four (4) staff confirmed the facility phone had not been working for a few weeks. During today's visit LPA Ramirez observed facility phone to be operational and in good repair. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Deficiencies are being cited for this investigation. Exit interview was conducted and a copy of this report, 9099-D and appeals rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240313153950
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: ABOVE AND BEYOND ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
85072(a)(6)
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85072 Personal Rights (a)In addition to Section 80072, the following shall apply.(6) To possess and use his/her own personal items, including his/her own toilet articles.This requirement was not met as evidenced by:
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Licensee will re-train staff on this regulation and re-trian staff on C1's behavior intervention plan. Staff will not remove C1's own personal items. Proof of re-training must be completed and submitted LPA Ramirez via email by 3/29/24.
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Staff took away C1's personal headphones and TV remote controller when C1 did not comply with staff requests to lower TV volume. Staff would search for these items in C1's room when C1 did not hand them over when requested.
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Type B
03/15/2024
Section Cited
CCR
85072(a)(9)
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85072 Personal Rights (a) In addition to Section 80072, the following shall apply.
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This requirement was not met as evidenced by: Facility phone was observed to not be in working order and was replaced by staff within 2 hours on 3/5/24.
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(9) To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies.

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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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3