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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603525
Report Date: 11/26/2024
Date Signed: 11/26/2024 12:40:29 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
06/17/2024 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240617163055
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:
11/26/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Eduardo AlvarezTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility is operating out of staff ratio.
Staff yell at a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit to deliver findings on the above allegations. LPA discussed the purpose of the visit with Administrator Eddie Alvarez.

The investigation consisted of: On 6/202/24, a physical plant tour was completed, and staff (S1-S8) were interviewed. No residents were interviewed due to limited comprehension. Record review was completed and copies of Face Sheets/Residents Identification/Emergency Information, IPP, IBSP, Physician's Reports, LIC 500 Personnel Report & staff roster, resident roster, timecard reports & schedules were obtained. On 10/21/2024, the Regional Office received Eastern Los Angeles Regional Center Corrective Action Plan.

During today's visit, LPA reviewed and obtained Staff Schedules [Nov. 17, 2024 - Nov. 30, 2024], Weekly Assignments, LIC 500 Personnel Report, and a copy of Lead RBT Adriana Harbin's completed ELARC's Residential Services Orientation Program.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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-20240617163055
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: 11/26/2024
NARRATIVE
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Allegation: Facility is operating out of staff ratio. It was reported that there have multiple times in which the facility was understaffed with less than 7 direct care staff. According to information obtained it is alleged that on April 28, 2024, the AM shift only had a total of 5 staff and the night shift was also out of staff ratio. There are 3 residents in placement. Two (2) residents have a 2 to 1 ratio, and one (1) resident has a 3 to 1 staff ratio. Eight (8) staff were interviewed of which, 6 out of 8 staff confirmed that on April 28, 2024 there were only five (5) staff working the AM shift because 2 staff called off and 1 staff had a family emergency. Administrator covered the shift. Staff acknowledged there are supposed to be always a minimum of 8 staff [7 staff + 1 lead staff]. According to staff interviews there are habitual staff that call off often without advance notice for personal reasons or because assignments are posted and they do not want to work with the challenging resident(s). Staff stated that many call offs occur on Fridays, Saturdays, and Sundays. Staff stated Administrator offers incentives for staff so that they can cover extra shifts when there are staffing shortages.

Based on timecard reports and schedules between dates 4/1/2024- 6/20/2024 the findings indicate that the following shifts did not meet required staffing ratios: 4/1/24 10PM - 6 AM, 4/8/24 6 AM - 2PM, 4/8/24 10 PM - 6 AM, 4/14/24 10 PM - 6AM, 4/16/24 10 PM-6 AM, 4/26/24 2 PM - 10 PM, 4/28/24 6 AM - 2PM, and 4/28/24 10 PM - 6 AM. Eastern Los Angeles Regional Center Quality Assurance staff conducted a series of announced and unannounced visits on 7/17/24, 8/7/24, 8/9/24, and 9/6/24, as a result several substantial inadequacies were issued. Based on investigations findings, there is sufficient evidence to corroborate the allegation.

Allegation: Staff yell at a resident. It is alleged lead RBT lstaff (S1) yells "No!" when resident (R1) requests to go places, and yells at resident (R2) when the resident is crying. A total of 8 staff were interviewed. Staff (S1) denied the allegation and reported that a former staff got fired mid June 2024 for telling resident (R1) to shut up. Two (2) out of 8 staff interviewed stated they have heard staff (S1) yell at residents. Two (2) staff reported that they have witnessed 3 other staff address residents in an aggressive, loud tone, intimidating, and demeaning manner. According to staff interviews, staff (S1) easily got frustrated and lacked patience. Additionally, three (3) other staff that have been heard speaking of residents in an inappropriate manner i.e. saying resident (R2) needs a spanking or conversations about beating up a resident. Based on interviews conducted the findings indicate that at least 4 staff have failed to treat residents(s) with dignity and respect. The majority of resident yelling is done when the Administrator is not present or during shift changes. The findings indicate unprofessional staff conduct towards residents has been occurring, but due to favoritism only some staff have been disciplined. Staff interviews support the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
An exit interview was conducted with Eduardo Alvarez. A copy of the report and appeal rights will be mailed and emailed due to printing issues.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240617163055
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: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2024
Section Cited
CCR
80065(a)
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Personnel Requirements. 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 was not met evidenced by:
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Administrator developed an attendance policy and stated it is strictly being in enforced.

Submit a written plan of correction, a copy of the attendance policy, and a copy of attendance policy training.
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Based on interviews and record review, the facility failed to meet required staff to resident ratio on 4/28/2024, and other dates, especially Fridays, Saturdays, and Sundays. This poses a potential health and safety risk to persons in care.
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Type B
12/10/2024
Section Cited
CCR
80072(1)
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Personal Rights. To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement was not met evidenced by:
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Administrator agreed to submit a written plan that states what measures were taken, a copy of the staff policy, and proof of staff training.
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Based on interviews conducted, the findings indicate staff (S1) and three other staff yelled and failed to treat residents(s) with dignity and respect. This poses a potential health and safety 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: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3