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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700701
Report Date: 12/20/2022
Date Signed: 01/24/2023 08:47:59 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221101143954
FACILITY NAME:ASIANA RESIDENTIAL SERVICESFACILITY NUMBER:
502700701
ADMINISTRATOR:KHAN, SAJIDAFACILITY TYPE:
735
ADDRESS:5020 TAMARA WAYTELEPHONE:
(209) 566-3933
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:6CENSUS: 6DATE:
12/20/2022
UNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Gina and SajiaTIME COMPLETED:
03:13 PM
ALLEGATION(S):
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Facility staff member hit resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Johnson arrived unannounced to conduct an investigation of the above mentioned allegation. LPA met with Staff and discussed the purpose of the visit.

Allegation: Facility staff member hit resident while in care.

Based on interviews conducted and records reviewed, R1 reported that S1 hit him with a closed fist on the right side of the head because R1 made a mess eating noddles. R1 stated that he did not mean to make a mess but he did. R1 also stated that S1 is nice to him, but this time he assaulted me.

S1 stated that he did not hit R1, S1 stated that R1 was eating and made a mess, S1 stated that he told R1 to clean -up the mess and R1 became angry and left the room.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
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 2
Control Number 27-AS-20221101143954
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ASIANA RESIDENTIAL SERVICES
FACILITY NUMBER: 502700701
VISIT DATE: 12/20/2022
NARRATIVE
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S1 stated again that he did not hit R1 and R1 and he have a great staff to client relationship. S1 stated that R1 may have been upset because the Licensee/Administrator was out of town.

LPA also interviewed staff regarding witnessing aggressive acts or physically hitting residents at the facility. All staff denied witnessing or participating in aggressive acts or hitting any residents at anytime.

The preponderance of evidence standards has not been met. Therefore, the allegation of "Facility staff member hit resident while in care at facility." is deemed UNSUBSTANTIATED.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were cited during this visit.

An exit interview was conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2