565801258-3-25-2022-29-AS-DPEA-CCZMH9-20220330093710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801258
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:31:31 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
02/18/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210218105226

FACILITY NAME:	MG FAMILY HOME		FACILITY NUMBER:	565801258
ADMINISTRATOR:	JOSE ONG		FACILITY TYPE:	735
ADDRESS:	814 DOLLIE STREET		TELEPHONE:	(805) 986-8908
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 6	DATE:	03/25/2022
		UNANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Jose Ong		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff caused injuries to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation initiated by LPA Lopez on 02/18/2021. Administrator Jose Ong arrived at the facility at 12:16 PM and the LPA explained the reason for the visit. During today's inspection the LPA conducted a brief physical plant tour of the facility with the Administrator.

On 2/18/2021, The Department received a complaint regarding an allegation of that staff caused injuries to a resident. It was alleged Resident #1 (R1) was trying to exit the facility and staff blocked R1. It was further reported that R1 sustained a black eye and while pulling R1’s bag R1 sustained bruising to their neck.

On 02/18/2021, LPA Lopez and Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison conducted a telephone interview with R1 and R1’s Representative.

Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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 29-AS-20210218105226

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: MG FAMILY HOME	FACILITY NUMBER: 565801258
	VISIT DATE: 03/25/2022

NARRATIVE

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On 2/18/2021, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures the complaint investigation was initiated telephonically via virtual call jointly with QAS Robison. Between 2:06 PM and 3:08 PM, LPA Lopez conducted interviews with Resident #2 (R2). The LPA requested pertinent records to be emailed to the LPA. On 02/24/2021, between 2:30 PM and 3:30 PM, FaceTime interviews were conducted with Staff #1 (S1)and Staff #2 (S2). On 02/25/2021, between 2:09 PM and 3:15 PM, FaceTime interviews were conducted with licensee representative Maria Miranda, Staff #3 (S3) and Staff # 4 (S4). On 03/02/2021, between 2:14 PM and 3:00 PM, a FaceTime interview was conducted with Staff #5 (S5). The LPA also reviewed the police report from the Ventura Police Department.

During the interview with R1, R1 stated a staff, name unknown, pushed R1 and punched R1 in the eye when R1 was attempting to leave the facility. R1 also stated a second staff dragged R1 on the floor. R1 eventually left the facility and took the bus to their family member’s home where law enforcement was contacted.

Interviews and record review revealed that on 02/12/2021, four (4) facility staff were present when R1 eloped from the facility. S5 followed R1 who walked to a shopping center several miles from the facility. Administrator, Jose Ong, drove to the shopping center and convinced R1 to return back to the facility. Approximately two hours later, R1 attempted to leave the facility again and S5 stated they blocked the door and held the door handle initially so R1 could not leave. R1 pushed S5 several times and S5 eventually lost grip of the door and R1 walk out of the facility. S5 advised Administrator on the telephone that R1 had left again. S5 was instructed by the Administrator to not follow R1 and that law enforcement will be notified, pursuant to the advice of Tri-Counties Regional Center. During the interview with S5, S5 denied pushing, punching or putting their hands on R1. S5 also stated they were the only staff involved in the incident. Interviews with the three (3) other staff who were present when the incident occurred revealed no involvement in the incident or observing any staff placing their hands on R1. Additionally, Oxnard/Ventura Police Department did not suspect any form of physical abuse and no case was open.

Based on the information obtained there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview and report reviewed with the Administrator. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

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