306003705-7-26-2023-28-AS-TVAO-CUZUG3-20230824153340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003705
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:41:10 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
07/19/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230719131240

FACILITY NAME:	COACHMAN HOME		FACILITY NUMBER:	306003705
ADMINISTRATOR:	RAFAEL TORRES		FACILITY TYPE:	735
ADDRESS:	9333 COACHMAN AVENUE		TELEPHONE:	(310) 567-9285
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY:	6	CENSUS: 3	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	01:21 PM
MET WITH:	Jaqueline Dungo Mikin - Assistant Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Staff hit client
Staff withheld food from client as a punishment

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 Jaqueline Dungo Assistant Administrator and explained the reason for the visit.

The investigation consisted of the following: LPA requested copies of staff/client roster. LPA conducted interviews with staff #1, #2 (S1-S2) and client #1-#3(C1-C3). LPA reviewed C1's file, requested copies of Individual Progress Plan Annual Review (IPP), Psychological Evaluation, Physician's Report, Incident report, and Medication sheet for July 2023. LPA requested copies of latest staff personal right's training.

The investigation revealed the following: Regarding allegations: Staff hit client and Staff withheld food from client as a punishment. It is alleged that on 7/18/23 Client #1(C1) was hit in the head by staff #1(S1) and staff send C1 to Day Program without breakfast because C1 woke up late.
(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: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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-20230719131240

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: COACHMAN HOME	FACILITY NUMBER: 306003705
	VISIT DATE: 07/26/2023

NARRATIVE

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Interview with assistant administrator revealed that on 7/18/23 C1 was prompted to complete morning routine about 3 times. C1 was verbally prompted by S1 and roommate regarding getting ready and having breakfast before transportation arrived. S1 went to the bedroom to check on C1, noticed C1 was sitting and leaning forward. S1 decided to check C1 by placing hand in C1's forehead and asked C1, "Do you feel sick or something?" C1 stated to want to go to Day Program. S1 then verbally prompted C1 to finish getting ready. Later, S1 noticed clients' transportation had arrived and packed C1's breakfast in C1's lunch bag to be taken to Day Program. However, S1 forgot to tell Day Program's Coach that C1 did not have breakfast and was in C1's lunch bag.

Interviews with clients revealed 3 out of 3 clients stated staff have not hit them or taken meals away as a punishment. Additional staff interview stated to not have observed other staff hit, punish, or withheld food from the clients or heard the clients state any of the allegations. Document review revealed facility submitted an incident report dated 7/20/23 to the Regional Center, which notes that on 7/18/23 S1 touched C1's forehead with forefinger to check if C1 was sick. C1 was running late to day program and breakfast was packed in lunch bag and send with C1. C1's IPP annual review dated 5/9/23 and Psychological Evaluation dated 7/18/03 note C1 needs verbal prompting on her daily activities. Although, C1 did not have breakfast on 7/18/23 at the home. Staff noticed C1 was taking longer to get ready, check C1 for symptoms that may required her to stay home, and packed the breakfast as transportation to Day Program was waiting for C1.

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 Jaqueline Dugon Mikin 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: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

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