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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001341
Report Date: 08/17/2023
Date Signed: 08/17/2023 10:38:01 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
05/26/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230526152159
FACILITY NAME:GRIDLEY ADULT SERVICES PROGRAMFACILITY NUMBER:
045001341
ADMINISTRATOR:CHERYL CHILDERSFACILITY TYPE:
775
ADDRESS:262 LITTLE AVENUETELEPHONE:
(530) 846-4988
CITY:GRIDLEYSTATE: CAZIP CODE:
95948
CAPACITY:25CENSUS: 22DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cheryl ChildersTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff restrained client in care.
INVESTIGATION FINDINGS:
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LPA HIratsuka, conducted this unannounced complaint visit. LPA conducted the investigation into the allegations above.

LPA interveiwed the complainannt and facility staff. LPA was unable to interview the client. The client was removed from program by the family. LPA reviewed the client's file. Interviews all agree the client was having a behavior and was on the floor when the client was picked up. The complainant stated the client was being held down by staff. The staff stated the client was hitting them and also themself. Staff stated the client laid on the floor by themself twice and when laying on the flloor grabbed at their face enough to cause some minor injuries. Staff stated they were holding the hands of the client to ensure the client wouldn't hurt themself but not holding the hands enough to prevent the client from standing up. Staff stated they were holding the hands to distract the client from grabbing at their face.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
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 2
Control Number 59-AS-20230526152159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GRIDLEY ADULT SERVICES PROGRAM
FACILITY NUMBER: 045001341
VISIT DATE: 08/17/2023
NARRATIVE
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Based on the above, LPA cannot prove or disprove the allegation based on each side having their version of events.

Due to the information gathered, LPA cannot determine the Staff restrained client in care. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2