198603679-5-23-2024-28-AS-RORN-D5PUW6-20240528155613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603679
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:15:45 PM

Substantiated

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
05/15/2024 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240515121425

FACILITY NAME:	MAINSTREAM CENTERS, INC		FACILITY NUMBER:	198603679
ADMINISTRATOR:	SOMMERS, TIA		FACILITY TYPE:	775
ADDRESS:	345 E ROWLAND STREET		TELEPHONE:	(626) 335-8110
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY:	120	CENSUS: 92	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Jack Hall - Program Director		TIME COMPLETED:	01:31 PM

ALLEGATION(S):

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Day Program Staff took inappropriate pictures of client while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Jack Hall (Program Director) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora obtained copies of the client and staff rosters, interviewed Program Director, Staff 1 - Staff 2 (S1 - S2), Client 1 - Client 5 (C1 - C5) and Regional Center Representative. LPA reviewed the facility observation report dated 05/08/2024 completed by S1.

The investigation revealed the following: regarding the allegation "Day Program Staff took inappropriate pictures of client while in care", it is alleged that on 05/08/2024 S1 took a picture of C1's anal area with S1's personal phone. Program Director stated that S1 did admit to taking the picture, but per S1 it was per C1's request. On that day, S2 took C1 to the restroom and when C1 wiped the anal area, C1 noticed blood on the toilet paper and informed S2. S2 reported this to S1 and S1 came and that is when S1 took the picture of the anal area. (Continued to LIC 9099).

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240515121425

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: MAINSTREAM CENTERS, INC	FACILITY NUMBER: 198603679
	VISIT DATE: 05/23/2024

NARRATIVE

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S1 was not available for an interview. However, there is an observation report dated 05/08/2024 and signed by S1, where S1 states that S2 called S1 to restroom to check on C1 because there was blood on the tissue and that a picture was taken by S1 per C1's request so that C1 can see it. S2 stated that S1 did take the picture of C1's anal area, but due to S1 and C1 speaking in Spanish, S2 could not say whether it was a request from C1 or if S1 just took the picture without C1's permission. C1 stated there was blood on the toilet paper and told S2 which led to S2 calling S1 to come. When S1 arrived, S1 told C1 that S1 is a nurse and S1 proceeded to take a picture of C1's anal area. C1 denied requesting or giving consent for S1 to take a picture. Regional Center Representative stated that they interviewed S1 and S1 admitted to taking the anal area picture, but it was due to C1's request and also admitted to telling C1 about being a nurse. Regional Center Representative stated that S1 is a retired nurse and S1 should have not used the title of nurse because S1 was hired at this day program as an office manager. Program Director stated that S1 should have not taken that picture because this day program is a non-medical place and the correct procedure was to document C1's discomfort and symptoms and contact C1's responsible party so that C1 can be taken to the hospital.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 3 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240515121425

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: MAINSTREAM CENTERS, INC	FACILITY NUMBER: 198603679
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/24/2024 Section Cited CCR 82072(a)(1)	1 2 3 4 5 6 7	Personal Rights: (a) Each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee is to comply with Title 22 Section 82072 at all times. Additionally, Licensee will conduct a staff training regarding this Title 22 regulation and submit a training log with all staff signatures to Community Care Licensing Division (CCLD) by 05/30/2024.
	8 9 10 11 12 13 14	Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. It was confirmed that S1 took a picture of C1's anal area.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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