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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405847
Report Date: 05/02/2022
Date Signed: 05/02/2022 04:02:06 PM

Document Has Been Signed on 05/02/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:HOWARD HOMEFACILITY NUMBER:
366405847
ADMINISTRATOR:TOLENTINO, LILIAN MA.FACILITY TYPE:
735
ADDRESS:4361 HOWARD AVENUETELEPHONE:
(909) 627-2546
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: DATE:
05/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Mario Figuracion, AdministratorTIME COMPLETED:
04:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted a case management visit to gather additional information in regards to the incident report received by the Department on 1/28/22. The visit is in response to the physical abuse allegations made by Client 1 against a former facility staff (S1). This visit consisted of a review of the clients' files, observations of the facility, and interviews with staff and client. During today's visit, LPA met with lead staff (S2), Patrice Amon, and Administrator (A), Mario Figuracion. LPA was allowed entry and explained the purpose of the visit.

During today's visit, LPA reviewed C1's file and obtained the following copies :
  • Individual Program Plan (IPP) 2020
  • DDS Client Evaluation Report 2020
  • Body Check - January 2022
  • Consumer Notes - 1/1/22 through 1/18/22

Interviews revealed that the facility were not notified of the allegation until S2 returned to work. Staff stated that the delay in reporting was due to the facility conducting an internal investigation, which concluded with S1 being terminated.

Refer to LIC-809D for deficiencies cited. An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed and provided to Administrator Figuracion
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/02/2022 04:02 PM - It Cannot Be Edited


Created By: Anna Bueno On 05/02/2022 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HOWARD HOME
FACILITY NUMBER: 366405847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
80061(d)

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Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
This requirement was not met as evidenced by:
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Facility staff attended n online a mandatory training on 2/10/2022. Facility staff provided proof of attendance by all staff.

This deficiency has been satisfied as of February 10,2022.
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Staff stated that the facility delayed reporting due to an internal investigation.
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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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


LIC809 (FAS) - (06/04)
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