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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603490
Report Date: 12/07/2023
Date Signed: 12/07/2023 04:41:31 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
07/14/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220714132734
FACILITY NAME:INSIGHT FOR LIFE EBSH @ GIANOFACILITY NUMBER:
198603490
ADMINISTRATOR:FALATOONZADEH, MELLADFACILITY TYPE:
737
ADDRESS:601 GIANO AVETELEPHONE:
(626) 295-2535
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:4CENSUS: 3DATE:
12/07/2023
UNANNOUNCEDTIME BEGAN:
04:24 PM
MET WITH:Mellad Falatoonzadeh, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff pushed resident.
Staff spoke to resident in an inappropriate manner.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Galarza & Sanjay Vaid conducted a subsequent complaint visit to investigate the above allegations.The purpose of the visit was discussed with Administrators Mellad Falatoonzadeh.

The investigation consisted of: On 7/20/2022, a physical tour of the facility, staff (S1- S7), and client (C2) were interviewed. Client (C1) refused to be interviewed. Document review was completed and copies of Identification and Emergency Information, Preplacement Appraisal, IPP, Physician Report, ISP, Behavior Plan, Psychiatric Assessment, LIC 500 Personnel Report, and client roster were obtained. During today's visit, a physical plant tour was conducted. No health and safety concerns were observed.

***Narrative continues next page.***
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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-20220714132734
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: INSIGHT FOR LIFE EBSH @ GIANO
FACILITY NUMBER: 198603490
VISIT DATE: 12/07/2023
NARRATIVE
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Allegation: Staff pushed resident. It is alleged that on on 7/11/2022, staff (S1) forcibly push resident (R1) down on a bench. Based on interviews conducted, resident (R1) was meeting with an outside agency staff and became highly agitated. The resident ran to the back door leading outside, and when staff (S1) asked the resident where they were going, the resident spit on S1's face and punched them in the arm/chest area. On that day, there were gardeners in the property that had tools everywhere because they were working on the sprinklers. Staff blocked the rear of the facility, but resident (R1) starting throwing wood chips on the floor. According to staff (S1) and staff witnesses, the resident was redirected verbally and guided back to the outdoor bench. Per staff interviews, the resident was only redirected verbally via Response Interruption and Redirection (RIRD) behavioral intervention technique. No Crisis Prevention Intervention (CPI) was used. LPA attempted to interview resident (R1), but they declined to be interviewed. Per record review, R1 has significant physical aggression and verbal aggression behavioral incidents per week. All staff interviewed denied the allegation. The findings indicate that staff were verbally redirecting R1 as the resident ran away from staff, and during the approximately 30 minute behavior incident. There in insufficient evidence to corroborate the allegation.

Allegation: Staff spoke to resident in an inappropriate manner. It is alleged that staff (S1) spoke to resident (R1) in a challenging manner during the 7/11/2022 behavior incident. According to interviews conducted, staff (S1) was the lead staff and two (2) additional staff (S4) was shadowing and staff (S5) was there as well ready to assist if needed. Staff (S1) stated they spoke to resident (R1) in a firm manner and reminded R1 not to act or communicate in an aggressive manner. The resident was told they needed to calm down. Per staff interviews, resident (R1) went back into the facility and asked for a pen and paper, which was given to the resident. The resident stomped on the ground, hit their head on the wall, and ran to staff (S8's) bag and tried to get things from it. Staff (S1) addressed R1 in a firm voice while the resident was attacking staff (S1). Staff interviews revealed that staff (S1) spoke to resident in an appropriate manner and followed facility intervention protocols. In addition, the San Gabriel/Pomona Regional Center conducted an investigation that rendered inconclusive findings. All staff denied the allegation. Therefore, there is insufficient evidence to corroborate the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22.

Exit interview was conducted with Administrator Mellad Falatoonzadeh. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2