198603607-9-26-2023-28-AS-TVAO-CW9NDH-20231003102222

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603607
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:42:10 PM

Unsubstantiated

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
09/20/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230920150400

FACILITY NAME:	SPRINGFIELD MANOR		FACILITY NUMBER:	198603607
ADMINISTRATOR:	BAIG, SHAHBAZ		FACILITY TYPE:	735
ADDRESS:	2526 NEW AVENUE		TELEPHONE:	(818) 846-4469
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	32	CENSUS: 31	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	Jaem Tan - Assistant Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff did not provide resident a 30 day notice of eviction.
Staff did not prevent resident from offering other residents illegal drugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Jaem Tan Assistant admisnitrator and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of client/staff roster. LPA conducted interviews with client #1-#4(C1-C4), assistant administrator, and staff #2-#3(S2-S3). LPA reviewed files for 3 clients, requested copies of admission agreement, house rules, physician’s reports, identification and emergency information, warning letters, copy of 30 day-notice dated 3/1/23.

The investigation revealed the following: Regarding allegation: Staff did not provide resident a 30-day notice of eviction. It is alleged administrator and another staff stated client will be kicked out if client doesn't stop taking drugs or tests positive for drugs again.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230920150400

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: SPRINGFIELD MANOR	FACILITY NUMBER: 198603607
	VISIT DATE: 09/26/2023

NARRATIVE

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Interviews with clients revealed, 3 out of 4 clients interview stated to not have been told or be aware of any client been told to leave the facility due to testing positive for drugs. 1 out of 3 clients interview stated to have been given warnings about testing positive and that a 30-day notice will be issued if another drug test came positive. Interviews with staff revealed 3 out of 3 staff interview stated none of the clients have been told to leave the facility. However, assistant administrator stated that clients are given verbal and written (three) warnings prior to give them a 30-day notice. Document review revealed C1 has two written warnings on file dated 9/13/23 and 9/21/23 noting C1 tested positive for drugs and house rule #8 states “alcohol, drugs, and any un-prescribed medication are prohibited at the facility.”

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not prevent client from offering other clients illegal drugs. It is alleged a client had meth and offered it to three other clients. Interviews with clients revealed 4 out of 4 clients interview stated to have never been offered drugs by other clients at the facility. 2 out of 3 staff stated to not have heard or been made aware of clients offering drugs to other clients. Assistant administrator stated that on March of 2023 a client was given a 30 day notice due to staff made aware that the client had offered drugs to a client at the facility. Documents reviewed revealed a 30 day notice dated 3/1/23 was issued C2 which notes one of the reasons for eviction as other: “offer drugs to other” clients. Although, in March of 2023 staff was made aware that a client had offered another client drugs. A 30 day-notice was issued as the facility’s plan of operation to prevent from the situation happening again.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Jeam Tan Assistant administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

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