037002705-6-5-2025-27-AS-KHOS-DHRL8F-20250618083151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 037002705
Report Date: 06/05/2025
Date Signed: 06/05/2025 03:48:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2025 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20250604151428

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: 27	DATE:	06/05/2025
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Renee Tang		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff leave the clients unattended.
Staff disclose personal information about the clients.
Staff are mistreating the clients while in care.

INVESTIGATION FINDINGS:

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On 6/5/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility to conduct the initial complaint visit. LPA met with Administrator Renee Tang (AD) and stated the purpose of the visit.

During this visit, LPA conducted a sample of 5 staff interviews and 5 client interviews. 1 of 5 client refused to be interviewed. Also during this visit, LPA reviewed 5 staff records and obtained copy of staff trainings. LPA conducted facility observation, including the main building and the sensory builing. Also during this visit, LPA conducted an observation of one group outing.

Allegation: Staff leave the clients unattended.
On June 5, 2025, LPA conducted an investigation regarding the allegation that staff leave clients unattended. As part of the investigation, the LPA conducted interviews, made facility and outing observations, and reviewed staff practices.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 4

Control Number 27-AS-20250604151428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMUNITY COMPASS, THE	FACILITY NUMBER: 037002705
	VISIT DATE: 06/05/2025

NARRATIVE

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LPA interviewed five staff members. Collectively, the staff denied ever witnessing any situation in which clients were left unattended by staff. They reported that clients are , at least, within visual or auditory distance at all times, particularly during outings. Staff collectively explained that the facility typically maintains a supervision ratio of one staff member to every three or four clients. Additionally, staff shared that during outings, if a staff member needs to use the restroom or assist a client in the restroom, they may request temporary supervision assistance from staff of another group to ensure that no clients are left unsupervised.

LPA also interviewed five clients; however, one client declined to be interviewed. The remaining four clients consistently reported that staff are always present, either within arm’s reach or visible distance. All four clients stated they have not witnessed any instance of staff leaving clients unattended. One client acknowledged that they are capable of being by themselves but noted that staff still ensure they are supervised during outings in case of emergency.

During the facility observation, this LPA observed appropriate staff-to-client ratios and active supervision. In the main building’s activity room, three clients were being supervised by one staff member. The rest of their clients went out in the community. In the Sensory Building, two staff members were observed supervising six clients.

Additionally, during an outing to a nearby bowling alley on June 5, 2025, this LPA observed four clients actively participating in a bowling activity under the supervision of one staff member, with no clients observed to be left unattended.

Based on interviews, observations, and information gathered during the investigation, there is insufficient evidence to support the allegation that staff leave clients unattended. Therefore, the allegation is determined to be UNSUBSTANTIATED. Note that an unsubstantiated findings means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20250604151428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMUNITY COMPASS, THE	FACILITY NUMBER: 037002705
	VISIT DATE: 06/05/2025

NARRATIVE

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Allegation: Staff disclose personal information about the clients.
An investigation was conducted by this LPA into the allegation that staff disclose personal information about clients in care. As part of the investigation, this LPA conducted staff and client interviews to gather relevant information.

LPA interviewed five staff members. Collectively, the staff denied ever witnessing or participating in the disclosure of clients' personal information. One staff member specifically expressed their understanding of confidentiality requirements under HIPAA and stated that staff are not permitted to share any client-related information with individuals outside the program. All staff emphasized the importance of maintaining client privacy and stated that the program actively reinforces confidentiality practices.

Additionally, LPA interviewed five clients; however, one client declined to participate. The four clients who were interviewed consistently stated that they have never witnessed any staff disclosing their personal information, nor have they observed staff sharing information about other clients with individuals outside the program.

Based on the information gathered through staff and client interviews, there is no evidence to support the allegation that staff have disclosed personal information about clients in care. Therefore, the allegation is determined to be UNSUBSTANTIATED
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Allegation: Staff are mistreating the clients while in care.
An investigation was conducted by this LPA into the allegation that staff are mistreating clients while in care. ThisLPA interviewed both staff and clients, reviewed staff training records, and observed the overall program environment to assess the validity of the allegation.

LPA interviewed five staff members. Collectively, the staff stated that they have not witnessed any incidents of mistreatment towards clients in the program. One staff member noted that on rare occasions, staff may raise their voice to get a client’s attention, but emphasized that such actions are never inappropriate or abusive. The staff member explained that this is done with the intention of ensuring clients' safety and well-being and not to harm or mistreat them.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20250604151428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMUNITY COMPASS, THE	FACILITY NUMBER: 037002705
	VISIT DATE: 06/05/2025

NARRATIVE

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LPA also interviewed five clients, although one client declined to participate. The four clients who were interviewed consistently reported that they have never witnessed any mistreatment of themselves or other clients by staff. They further clarified that they have never been yelled at or physically harmed by staff. All clients expressed satisfaction with the program, noting that they enjoy attending and have no issues with the staff. They also stated that staff treat them with respect.

Additionally, a review of staff training records indicated that staff receive comprehensive training in areas that are essential for ensuring the well-being of clients. This includes training on consumer services, development and implementation of Individual Program Plans (IPP), identification and reporting of consumer abuse, consumer rights, and various health and safety protocols. Notably, training also covers topics like reporting elder and dependent adult abuse, crosswalk safety, and appropriate communication with people with disabilities. This training is designed to reinforce a culture of respect and care for clients.

Based on interviews with staff and clients, as well as a thorough review of staff training, there is no evidence to support the allegation that staff are mistreating clients. Therefore, the allegation is determined to be UNSUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.

Exit interview was held and a copy of this report and appeal rights were provided.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

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