032700845-9-19-2022-27-AS-KHOS-CJWTQT-20221005145629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 032700845
Report Date: 09/19/2022
Date Signed: 09/19/2022 02:01:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/23/2022 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220523091540

FACILITY NAME:	SUNRIDGE PLACE		FACILITY NUMBER:	032700845
ADMINISTRATOR:	SIX, ZULLY		FACILITY TYPE:	735
ADDRESS:	14124 LUPE ROAD		TELEPHONE:	(209) 296-5574
CITY:	PINE GROVE	STATE: CA	ZIP CODE:	95665
CAPACITY:	4	CENSUS: 4	DATE:	09/19/2022
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Zully Six		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff handled resident in rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to this facility unannounced to deliver complaint investigation findings. LPA Valerio was met by Administrator Zully Six and explained the purpose of the visit.
The department has determined the following as it relates to the allegation: staff handled resident in a rough manner

According to a report dated 05/17/2022, an outside agency staff reported that a resident (R1) from Sunridge Place informed the agency that a staff member (S2) grabbed R1's wrist and left a mark. According to an interview conducted by LPA Valerio, outside agency staff could not confirm if a mark was seen on R1's wrist that day or days after. Although it was reported to them, they did not witness the incident. It was said the incident occurred at R1's placement home. Another staff member from the agency stated that they did not observe any bruises or marks on R1's wrist. The outside agency does daily body checks and notes show no sign of bruising or marks.
Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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 27-AS-20220523091540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRIDGE PLACE	FACILITY NUMBER: 032700845
	VISIT DATE: 09/19/2022

NARRATIVE

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LPA interviewed 3 individuals from two other outside agencies. According to their interviews, they do not have current concerns regarding the facility. One agency had an internal investigation, which results are unknown at this time. However, the individual could not say whether the allegation is true or false due to R1's past behaviors. The other agency provided LPA documentation relevant to the investigation and stated their observations of staff interactions have been positive.

LPA Valerio interviewed facility staff. Interviews with staff 4 and staff 5 were attempted and unsuccessful. According to staff 1 (S1), no incidents have occurred that resulted in a resident handled in a rough manner by staff. S1 is at the home frequently and has never observed any staff handling residents in a rough manner. According to staff 3 (S3), S3 stated, "if anything, it is us protecting ourselves from getting hit or protecting other residents from being hit or rough handled. We all do the best we can, and document everything we can." According to an interview with S2, S2 believes if anyone had a concern with the resident being in the home, the resident should have been moved out of the facility. S2 stated S2 has never handled any residents in a rough manner. S2 stated there was an incident involving S2 and R1. S2 was at a desk filling out paperwork. R1 went up to S2 and tried to grabbed the papers. S2 told R1 that R1 could not grab the papers. R1 proceeded to attempt to grab the papers while charging S2 with a pencil in R1's hand. S2 stated, "I grabbed [their] wrist because I did not know [their] intentions." According to interviews, no other staff or residents witnessed the incident.

According to records review from an outside agency and the facility, a daily note was written on 05/17/22. The daily note reads, "05/17/2022 - Tuesday, Very impulsive and unsafe with action. "[R1] grabbed papers from my desk, I removed [their] hand from my desk and [they] lunged at the desk and me with a sharp pencil in [R1] right hand. I stopped [R1] by grabbing […] wrists and told [R1] to stop. I was worried [they] could hurt [themselves] with [the] pencil." According to record documentation, records show that R1 has behaviors that may be sudden or outburst that require staff to attempt to redirect or de-escalate the resident. If staff are faced with such behaviors, they have been trained to act in a specific manner. The document states if the resident "…engages in less severe problem behaviors (verbal aggression, emotional outbursts, and noncompliance) staff will: Minimize attention (e.g. divert eye contact, use short direct statements only when needed, do not provide physical touch unless necessary to keep staff and consumers safe) for the specific problem behavior." Based on record review, staff used physical touch to ensure the safety of staff and resident.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220523091540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRIDGE PLACE	FACILITY NUMBER: 032700845
	VISIT DATE: 09/19/2022

NARRATIVE

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According to interviews with residents, there were no reports of being handled in a rough manner. R1 stated staff touch R1 arms to assist with ADLs. R2 stated R2 enjoys living at the facility and the staff are nice. No health or safety concerns were noted based on interviews.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. Exit interview was held with Administrator Zully Six, and a copy of report was left at the facility.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC9099 (FAS) - (06/04)

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