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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011405349
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:25:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2023 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20230209155140
FACILITY NAME:PALM TREE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
011405349
ADMINISTRATOR:BERTHA REEDFACILITY TYPE:
735
ADDRESS:2212 - EAST 19TH STREETTELEPHONE:
(510) 532-7785
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:11CENSUS: 5DATE:
06/22/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Nathaniel Reed, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Client is being physically abused while in care resulting in bruises and scratches
INVESTIGATION FINDINGS:
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On 6/22/2023 at 1:45 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegation. LPA met with Nathaniel Reed, Administrator and explained the purpose of the visit.

During the course of investigation, the Department interviewed facility staff, facility residents, day program staff, Regional Center of the East Bay (RCEB) staff, Paratransit staff, Adult Protective Services (APS) staff and the Oakland Police Department (OPD). The Department reviewed R2's records including Individual Program Plans dated 11/05/22 and 4/23/21, 2 special incident reports dated 2/02/23, LIC601 Identification and Emergency Information dated 1/03/23, LIC602 Physician’s Report dated 7/20/21, Admission Agreement dated 10/16/2012 and the facility’s staff schedule for February 2023.

***report continues on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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 3
Control Number 15-AS-20230209155140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PALM TREE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 011405349
VISIT DATE: 06/22/2023
NARRATIVE
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***report continues from LIC9099***

On the morning of 2/02/23, W1 observed R2 being kicked by a female facility staff person outside of the facility’s front door. The staff observed kicking R2 was later identified as S1. W1 reported the incident to her supervisor and an APS report was filed. When R2 arrived at his day program on 2/02/23 staff observed cuts and bruises to R2’s face and ear. The injuries were documented by day program staff (S2) in an SIR.

During the course of the investigation interviews with 3 of 6 residents (R4, R5 and R6) confirmed that they witnessed S1 using a yellow stick to hit R2 on multiple occasions. R4, R5 and R6 stated that S1 keeps the stick in her room at the facility under her bed. The stick was located by investigators in the room S1 uses as her sleeping quarters. The administrator verified that the stick belonged to S1. A photo of the stick was shown to R4, R5 and R6 who verified that was the stick S1 used to hit R2.

The Department has investigated the complaint alleging that client is being physically abused while in care resulting in bruises and scratches. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.


Exit interview conducted, a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20230209155140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PALM TREE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 011405349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2023
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights
(a)...each client shall have personal rights which include, but are not limited to, the following:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation...
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S1 is to be immediately excluded from the facility. LPA observed that S1 left the facility.
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mental abuse, or other actions of a punitive nature.
Based on interviews, the licensee did not comply with the section above for R2 being hit with a stick by S1 which poses immediate health and personal right risks to person in care. A $500 civil penality is assessed today.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3