Complaint Investigation Report

198602952-1-18-2024-28-AS-TVAO-CZRTSH-20240123135907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

GREATER LA AC/SC , 1000 CORPORATE CNTR DR. ST 500

This is an official report of an unannounced visit/investigation of a complaint received in our office on

01/04/2024 and conducted by Evaluator Kimberly Ramirez

COMPLAINT CONTROL NUMBER: 28-AS-20240104165631

Facility is not meeting the needs of a resident in care.

This is an amended report for the purpose of correcting allegation. This amended report does not change the findings.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 01/11/24 regarding the above allegations. LPA Ramirez was met by Administrator Estanislao and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Client Roster (LIC 9020), Staff #1 - 6 interviews(S1 – S6), Attempted interview of Client#1- 3 (C1-C3), Nearby neighbors-Witness #1-3 (W1-W3) copies of Client #1-4 (C4): Face Sheet, Identification and Emergency Information, San Gabriel/Pomona Regional Center Individual Program Plan (IPP), Facility/Program Special Incident Reports dated 09/2023 through 11/2023, Receipt dated 01/05/2024, Request for supplies from 12/2023 through 01/11/2024, Bi-weekly Employee Summary Report dated 01/01/2024 through 01/14/2024, Employee handbook and physical plant tour.