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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200030
Report Date: 09/08/2021
Date Signed: 09/08/2021 11:42:21 AM

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
03/03/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210303154431
FACILITY NAME:CROW CANYON RESIDENTIAL CARE IVFACILITY NUMBER:
079200030
ADMINISTRATOR:RUFFY B. YUFACILITY TYPE:
735
ADDRESS:1385 JENSEN DRIVETELEPHONE:
(925) 432-8786
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 6DATE:
09/08/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Yolanda Venegco, House ManagerTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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On 09/08/2021 at 11:00AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegation. LPA met with Yolanda Venegco, House Manager, and explained the reason for the visit.

During the course of the investigation, LPA conducted interviews with staff, witness, obtained and reviewed records. Records indicated the incident occurred on 2/11/2021 and Client 1 (C1) was taken to urgent care on 2/17/2021. During interviews Staff 3 (S3) stated she observed the abrasion, applied first aid, and reported it to Staff 2 (S2), unknown exact date. S2 stated she observed bruise on 2/17/2021 and took C1 to urgent care to make sure there were no broken bones.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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-20210303154431
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: CROW CANYON RESIDENTIAL CARE IV
FACILITY NUMBER: 079200030
VISIT DATE: 09/08/2021
NARRATIVE
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Continued from LIC9099.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210303154431
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: CROW CANYON RESIDENTIAL CARE IV
FACILITY NUMBER: 079200030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary...medical or dental services... to the nearest available services. This requirement was not met as evidence by:
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Administrator agreed to construct a procedure for when to take a client to the doctor for treatment. Administrator will train all staff and submit procedure and in-service training documentation to CCLD by POC date.
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Based on record review and interviews Licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3