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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801257
Report Date: 06/29/2022
Date Signed: 06/29/2022 04:41:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220622144305
FACILITY NAME:EJ2 FAMILY HOMEFACILITY NUMBER:
565801257
ADMINISTRATOR:MARIA MIRANDAFACILITY TYPE:
735
ADDRESS:1210 NELSON PLACETELEPHONE:
(805) 271-9449
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 5DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Jose OngTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Client was not accorded dignity with their personal relationship with Staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10 day complaint investigation inspection at the facility today. The LPA initially met with staff and explained the reason for today's visit. Assistant Administrator Jose Ong arrived at the facility at 1:00 PM and was advised of the reason for today's visit. When the LPA arrived there were two staff and three clients present.

Prior to this visit, today, the LPA conducted a Collateral inspection and interviewed Client #1 (C1) at 11:06 AM. During today's inspection at the facility, the LPA conducted interviews with Client #2 (C2), Client #3 (C3), Staff #1 (S1), and Staff #2 (S2) between 12:50 PM and 1:20 PM. At 1:25 PM, the LPA conducted a record review.

Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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 29-AS-20220622144305
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EJ2 FAMILY HOME
FACILITY NUMBER: 565801257
VISIT DATE: 06/29/2022
NARRATIVE
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The allegation of 'Client was not accorded dignity with their personal relationship with Staff', alleges Staff #1 (S1) made a comment to Client #1 (C1) about the sexual orientation of C1's family member. During the interview with C1, C1 stated they may have misunderstood what S1 said to C1 and denied ever hearing S1 speak inappropriately about their family member. Interviews with C2, C3, and S2, revealed they never observed S1 talk about C1's family members. During the interview with S1, S1 denied ever speaking about C1's family member's sexual orientation or ever speaking inappropriately about the family member to C1. Record review revealed seven documented telephone calls from C1 to staff since they moved out of facility.

Based on the interviews and record review conducted, there is insufficient evidence to support the allegation of 'Client was not accorded dignity with their personal relationship with Staff' occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted with Administrator Jose Ong. A copy of the report and appeal rights will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2