079200383-12-21-2023-15-AS-YFLS-CYYTRG-20231229135731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200383
Report Date: 12/21/2023
Date Signed: 12/21/2023 12:53:25 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
09/29/2023 and conducted by Evaluator Paris Watson

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230929095121

FACILITY NAME:	SVS CONCORD ADULT DAY PROGRAM		FACILITY NUMBER:	079200383
ADMINISTRATOR:	SHAVILA WRIGHT		FACILITY TYPE:	775
ADDRESS:	2300 STANWELL DRIVE SUITE B		TELEPHONE:	(925) 849-8750
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	60	CENSUS: 18	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Shanay McDonald, Program Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff inappropriately restrain resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/21/2023 at 12:15 PM Licensing Program Analysts (LPA) P. Watson arrived unannounced to deliver findings for the above allegation. LPA met with Program Director, Shanay McDonald, and explained the purpose of the visit.

During the initial 10-day complaint visit, LPA toured facility, interviewed staff and collected the following documents: Staff CPI cards, C1’s physician’s reports, doctors notes, SIR’s, and Individual Needs and Services Plan.

Report continues on 9099 C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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 3

Control Number 15-AS-20230929095121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SVS CONCORD ADULT DAY PROGRAM	FACILITY NUMBER: 079200383
	VISIT DATE: 12/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was alleged that, Facility staff inappropriately restrain resident.

Based on interviews with staff (S1, S2) and Program Director, a harness and hand restraint were used for C1 during transportation from and to their residency. Program Director stated that the use of the harness and hand restraint has been used for transportation since before they became the Program Director. LPA asked why they are used, Program Director stated that C1 has a habit of biting themselves and trying to remove their seat belt during transportation. Program Director stated that the harness is left on C1 throughout the time at program, but their hands are not in the restraints. S1 stated that when C1 is picked up from their residency they have the harness on, once C1 is in the facility van staff place C1 hands into a side hand restraint and they are left on for about 15 minutes then removed once they arrival at program. S1 ensured LPA that the hand restraints are not too tight but tight enough to make sure C1 does not get out during the ride, S1 also stated that staff make sure the restraint is loose enough to not harm C1 wrists. S2 stated that sometimes C1 did not need to use the hand restraints on the way to their residency unless they had a behavior prior to drop offs. LPA asked how does C1 act during their behavior. S2 stated that C1 bites themselves and shows aggression while biting themselves as evidence by pulling their skin. S2 stated that they have observed that C1 being hungry and/or constipated seems to trigger behaviors, S2 makes sure they have snacks available for C1 during program to ensure they do not have a behavior. LPA was informed that the facility no longer uses the harness and hand restraint for C1.

Based on LPAs interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of this report provided along with appeal rights.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230929095121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SVS CONCORD ADULT DAY PROGRAM	FACILITY NUMBER: 079200383
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/28/2023 Section Cited CCR 82072(a)(E)(1)	1 2 3 4 5 6 7	82072 Personal Rights (a) Each client shall have personal rights which include, but are not limited to, the following: (E) Protective devices including, but not limited to, helmets, elbow guards, and mittens that do not prohibit a client's mobility but rather protect the client from self-injurious behavior.. (1) All requests to use protective devices shall be in writing and include a written order of a physician indicating the need for these devices...	1 2 3 4 5 6 7	Day Prgram has stopped using harness and hand restraints for C1. Deficiency is cleared Administrator will review regulation and ensure that next time a written request with approval from CCL is in place prior to using devices for clients in care
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and photographic proof, the facility utilized a harness and hand restraint for C1 without CCL approval which poses/posed an immediate/potential Health, Safety or Personal Rights risk to persons in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3