037002705-12-22-2021-27-AS-KHOS-C9YNTS-20211223094514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 037002705
Report Date: 12/22/2021
Date Signed: 12/22/2021 02:10:50 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
10/21/2021 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211021083121

FACILITY NAME:	COMMUNITY COMPASS, THE		FACILITY NUMBER:	037002705
ADMINISTRATOR:	SKIDMORE, RICHARD		FACILITY TYPE:	775
ADDRESS:	823 SOUTH HIGHWAY 49		TELEPHONE:	(209) 223-3845
CITY:	JACKSON	STATE: CA	ZIP CODE:	95642
CAPACITY:	60	CENSUS: 22	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Richard Skidmore		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Client sustained an unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver investigation findings. LPA was screened for COVID-19 symptoms with temperature taken prior to being allowed entry into the program. Facility staff confirmed zero participants and zero staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

The investigation was completed by LPA Valerio and consisted of interviews, review of facility records, and review of medical records. The department determines the following for the allegation: Client sustained an unexplained injury while in care

According to Special Incident Report dated 09/10/21, day program staff discovered a bump on participant 1's (P1) forehead after P1's hat fell off in the changing room. The bump was "approximately 3/4 x 3/4 inches in circumference. Program staff notified the program manager, administrator, P1's responsible party, and Valley Mountain Regional Center. P1's responsible party transported P1 to the hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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 27-AS-20211021083121

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: COMMUNITY COMPASS, THE	FACILITY NUMBER: 037002705
	VISIT DATE: 12/22/2021

NARRATIVE

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According to medical records, the CT scan showed no acute intracranial hemorrhage, no clavarial fracture, left forehead and left frontal scalp soft tissue edema, and presence of multiple ventricular catheters.

According to staff interviews, staff present during the incident stated the incident did not happen at The Community Compass, Inc. Staff 1 (S1), Staff 2( S2), Staff 3 (S3), and Staff 4 (S4) stated P1 appeared to be at baseline and did not observe any discomfort upon arrival. Staff did not see any participants approaching P1 nor did they see P1 fall. P1 was in his chair during activities. The only time P1 was out of chair was in the changing room. Staff 3 stated, "I went to change [P1], the hat moved back, and I noticed the bump. I continued to change [P1] and called [Staff 1] after I was done."

Due to communication barriers, interviews with Participant 1 and Participant 2 were deemed unsuccessful.
According to an interview with Blue Mountain Transportation, the bus driver stated no incidents occurred on the bus with P1. Individuals who come on the bus are assisted by family members or facility staff.

According to an interview with P1's responsible party, the incident could not have happened anywhere except the Day Program. Responsible Party for P1 did not observe a bump before leaving home and watched P1 get buckled in the bus. Responsible Party stated, "Something happened there, and no one is telling truth. On the incident report, they had [P1] on the schedule at 11:20 AM going to the sensory building. On the daily log, they said [P1] is at the restroom at 11:20 AM."

According to Valley Mountain Regional Center (VMRC) interviews, VMRC was notified of the incident involving P1. VMRC could not determine what may have happened based on what was shown to VMRC.

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, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Administrator Richard Skidmore.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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