State of California - Health and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: Department of Public Health Page 1 of 2 17-1220-0004097-S Date: 07/16/2007 Time: _________ Type of Visit : Complaint Investig. Incident/Complaint No.(s) : CA00084508 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD 3530 POMONA BLVD POMONA, CA 91769 (909)595-1221 Intermediate Care Facility/Developmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 Capacity: 944 DEADLINE FOR COMPLIANCE 8/5/07 12:00 a.m. CLASS B CITATION -- PATIENT RIGHTS 76525(a)(7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. Name of Evaluator: HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE State of California - Health and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: Department of Public Health Page 2 of 2 17-1220-0004097-S CLASS AND NATURE OF VIOLATIONS Date: 07/16/2007 Time: _________ SECTIONS VIOLATED ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE