079200706-8-17-2023-15-AS-HHUL-CUYR4A-20230823124113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200706
Report Date: 08/17/2023
Date Signed: 08/17/2023 03:57:26 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, 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
02/09/2023 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230209143157

FACILITY NAME:	J&M RESIDENTIAL CARE		FACILITY NUMBER:	079200706
ADMINISTRATOR:	RODRIGUEZ, JOSE		FACILITY TYPE:	735
ADDRESS:	2831 VISTA WAY		TELEPHONE:	(925) 529-0923
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 5	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Bernardo Herrera, Direct Support Professional		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Resident sustained a head injury in care due to staff neglect.

Facility staff did not notify resident's responsible person of injury to resident.

Facility staff hit resident(s).

INVESTIGATION FINDINGS:

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On 8/17/2023 at 3:25pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Bernardo Herrera, Dispatch Support Professional (DSP), and explained the purpose of the visit. Licensee, Minerva Gonzalez, arrived at 3:45pm.

During the course of the investigation, the Department conducted interviews with staff, Reporting Party (RP), obtained and reviewed records. On the above allegation, resident sustained a head injury in care due to staff neglect, based on medical records dated 1/16/2023 the cause of injury was an accidental fall. The Department interviewed four (4) staff. Three (3) of the staff were present at the time of the incident. Staff 3 (S3) and Staff 4 (S4), stated that Client 1 (C1) stood up from the kitchen table to go and sit on the floor, fell backwards, and hit his head on the corner of the wall. Staff also stated that at the time of the incident C1 was wearing a different pair of socks than what he normally wears, and it caused C1 to slip. Based on the investigation the above allegations are unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

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

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Control Number 15-AS-20230209143157

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: J&M RESIDENTIAL CARE	FACILITY NUMBER: 079200706
	VISIT DATE: 08/17/2023

NARRATIVE

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Continued from LIC9099.

Staff also stated that at the time of the incident C1 was wearing a different pair of socks than what he normally wears, and it caused C1 to slip. Based on the investigation the above allegations are unsubstantiated.

On the allegation facility staff did not notify resident’s responsible person of injury to resident. During the interview with the reporting party (RP) it was stated that C1’s responsible party was contacted, however RP was unsure of the exact date. Incident report dated 1/16/2023 indicates licensee contacted C1’s responsible party. S1 was interviewed and stated that the responsible party was contacted and arrived at the hospital after the procedure was complete for C1. S1 also stated that the responsible party took C1 with them from the hospital and returned C1 back to the facility later in the evening. Currently C1 no longer resides at the facility. The Department made several attempts to contact the responsible party but did not receive a response.

On the allegation facility staff hit resident(s). LPA interviewed staff, clients, and reporting party. RP states, C1’s responsible party was informed by another visitor of the facility, (unknown name or date) they observed staff hit a client, there were no names provided. During interviews with staff, they denied hitting or observing other staff hit clients. LPA was able to interview two (2) of six (5) clients and was unable to interview the other (3) due to being nonverbal. Clients that were interviewed stated they had never witnessed a staff hit any of the clients.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report is provided.

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

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