198602214-11-9-2022-28-AS-RORN-CLDR9C-20221121114916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602214
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:08:38 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
11/07/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221107084807

FACILITY NAME:	CENTER FOR BEHAVIORAL CHANGE 7		FACILITY NUMBER:	198602214
ADMINISTRATOR:	EBENEZER AKINOLA		FACILITY TYPE:	735
ADDRESS:	772 COBRE CT		TELEPHONE:	(909) 629-1715
CITY:	POMONA	STATE: CA	ZIP CODE:	91768
CAPACITY:	5	CENSUS: 3	DATE:	11/09/2022
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Naason Riddell - Direct Support Professional (DSP)		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Facility staff hit resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Naason Riddell (DSP) and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of the client and staff rosters and interviewed Administrator, Staff 1 - Staff 3 (S1 - S3), Client 1 - Client 3 (C1 - C3) and San Gabriel/Pomona Regional Center (SGPRC) representative. LPA requested copies of C1's Individual Program Plan (IPP) and unsual incident report dated 11/04/22.

The investigation revealed the following: regarding the allegation "facility staff hit resident”, it is alleged that S3 hit C1's right hand and arm on the morning of 11/03/22. Staff intervierwed denied the allegation and stated that C1 got physically aggresive and hit himself with the wall due to another client laughing at him. Clients interviewed could not corroborate the allegation. C1 confirmed that the staff did not hit C1 and that C1 hit the wall with the right arm. (CONTINUED TO LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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 28-AS-20221107084807

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: CENTER FOR BEHAVIORAL CHANGE 7	FACILITY NUMBER: 198602214
	VISIT DATE: 11/09/2022

NARRATIVE

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Interview with the San Gabriel/Pomona Regional Center (SGPRC) representative revealed that C1 has a history of fabrication, self injury, and that on the same day of the incident C1 retracted the statement that S3 hit C1 and stated that C1 hurt the right arm by hitting the wall. Reviewed of C1's Individual Program Plan (IPP) revealed that C1 does have a history of fabrication and self injury.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held and a copy of the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC9099 (FAS) - (06/04)

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