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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603525
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:45:44 PM

Substantiated


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
03/06/2025 and conducted by Evaluator Noemi Galarza
COMPLAINT CONTROL NUMBER: 28-AS-20250306112745
FACILITY NAME:LAMBERT PLACE, THEFACILITY NUMBER:
198603525
ADMINISTRATOR:ALVAREZ, EDUARDOFACILITY TYPE:
737
ADDRESS:13304 LAMBERT RDTELEPHONE:
(909) 631-8521
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:3CENSUS: 3DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Eduardo Alvarez, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility is not following program plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator Eduardo Alvarez.

The investigation consisted of: LPA reviewed records, interviewed staff (S1-S3), toured the facility, and obtained relevant complaint documents i.e.2 incident reports [9/21/24 & 11/30/24], R1's Identification and Emergency Information/ Face Sheet, IPP, staff roster, and LIC 500 Personnel Report.


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

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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 3
Control Number 28-AS-20250306112745
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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525
VISIT DATE: 03/11/2025
NARRATIVE
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Allegation: Facility is not following program plan. It was reported that on two (2) dates; 9/21/24 & 11/30/24 staff conducted improper CPI holds on resident (R1). On 9/21/24, R1 was in the activity room and due to self-injurious behaviors staff determined a CPI hold was needed. However, the 3rd staff supported R1's head, which is not part of the program design. On 11/30/24, R1 was being non-compliant in the kitchen area, and former staff (S4) restrained the resident from behind by giving a bear hug and moving the resident. No other staff were involved in this incident. The facility has 2 CPI trainers. All 3 staff acknowledge the two aforementioned CPI incidents used improper CPI hold techniques that are not part of the program design emergency intervention training. CPI trainers stated they did not know that the program design does not allow head support holds. Based on record review, the program design Emergency Intervention Plan does not include any head support hold. Administrator is required to debrief with staff after each incident, but did not after the 11/30/24 incident. ELARC issued a Corrective Action Plan and CPI trainers are scheduled to conduct CPI training this month reflective of the program design.

Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiency is being cited according to California Code of Regulations, Title 22. Refer to LIC 9099D.

Exit interview was conducted with Administrator and a copy of appeal rights and report was issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250306112745
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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
80022(k)
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Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

This requirement was not met evidenced by:
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Administrator stated facility CPI trainers will retrain all staff, and will be completing training by early April 2025. Additionally, monthly 20-minute CPI refresher training will continue to be completed.

Submit proof that all staff have received CPI training.
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Based on record review and interviews, the findings indicate that on dates 9/21/24 & 11/30/24 staff performed improper CPI holds on resident (R1). The techniques used are not part of the program design. This poses a potential health, safety, personal rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3