198603562-8-8-2023-28-AS-LHIS-CUPPUF-20230814113727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603562
Report Date: 08/08/2023
Date Signed: 08/08/2023 02:47:12 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
08/01/2023 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20230801140935

FACILITY NAME:	VICTORY RESIDENTIAL		FACILITY NUMBER:	198603562
ADMINISTRATOR:	LUCAS, OMOBOLANLE		FACILITY TYPE:	735
ADDRESS:	730 E ALWOOD STREET		TELEPHONE:	(323) 804-5062
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	4	CENSUS: 3	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Administrator Anthony Johnson		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff hit resident
Staff failed to provide adequate food service
Staff provided inadequate supervision
Staff failed to meet resident's needs

INVESTIGATION FINDINGS:

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On 8/8/23 at 8:52 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Staff #1 (S1) and explained the reason for the visit. S1 contacted the Administrator (Anthony Johnson) at 8:55 a.m. The Administrator arrived at 9:05 a.m., and LPA explained the purpose of the visit. Upon arrival S1 stated all clients are at the day program.

During today’s visit LPA toured the facility with Administrator. LPA obtained resident/ staff roster, facility menu, photos of food supplies and SIR dated 8/1/2023. LPA conducted file review and obtained copies of C1’s Referral dated 8/11/2014, IPP dated 12/22/2021, needs and service plan, July medication list and behavioral quarterly report. LPA also interviewed: Administrator and a total of two (2) staff who shall be referred to as S1 and S2. S2 was not at the facility and was interviewed via phone. LPA interviewed a total of 3 clients who shall be referred to as: C1 through C3.

Report continued 9099c.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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 3

Control Number 28-AS-20230801140935

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: VICTORY RESIDENTIAL	FACILITY NUMBER: 198603562
	VISIT DATE: 08/08/2023

NARRATIVE

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The investigation reveals the following: Regarding "Facility staff hit resident”. It is alleged that staff hit C1. LPA reviewed C1’s IPP and observed a history of fabrication. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating staff has never hit the clients. The administrator further stated that this is the first time the facility has heard of the allegation. 2 out of 2 staff denied the allegation, stating they have never hit any of the clients. 3 out of 3 clients denied the allegation, stating staff has never hit them and they have not witness staff hitting another client.

The investigation reveals the following: Regarding "Staff failed to provide adequate food service”. LPA toured the facility with the Administrator and observed the emergency food supply and the pantry. LPA observed and took photos of sufficient two-day supply of perishables and a seven-day supply of non-perishables. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating the facility receives weekly groceries and deliveries from Walmart. The Administrator further stated clients always receives seconds when requested. 2 out of 2 staff denied the allegations stating the clients receive breakfast, snack, lunch, snack, and dinner. Staff further stated if the clients ask for more food the facility has always provided the clients with more food. 3 out of 3 residents stated the facility always provide them with enough food.

The investigation reveals the following: Regarding "Staff provided inadequate supervision” It is alleged a client left the house without clothing. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating the facility always have 2 staff on duty. The Administrator further stated there was an incident with a client who attempted to absent without leave (AWOL) and was exhibiting certain behaviors. Staff followed closely behind the client and tried to redirect the client. Staff was always present when the client attempted to AWOL. 2 out of 2 staff denied the allegations stating the facility schedules 2 staff during the day and 1 staff at night. 3 out of 3 clients stated the facility has 2-day staff and 2-night staff.

Report continued on 9099c

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230801140935

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: VICTORY RESIDENTIAL	FACILITY NUMBER: 198603562
	VISIT DATE: 08/08/2023

NARRATIVE

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The investigation reveals the following: Regarding "Staff failed to meet resident’s needs”. During the visit LPA interviewed the Administrator. The Administrator denied the allegation stating the facility has always met the needs of the clients and there has been no complaints from the clients regarding there needs are not being met. 2 out of 2 staff denied the allegation stating all the client’s needs are being met. 3 out of 3 clients denied the allegation and stated the facility staff are their family and they are happy at the facility.

Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid,

there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the
allegation is UNSUBSTANTIATED.

Exit interview conducted with Anthony Johnson and a copy of this record provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3