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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157203519
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:07:22 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2023 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230413141153
FACILITY NAME:INDEPENDENCE AT CENTENNIAL GROVEFACILITY NUMBER:
157203519
ADMINISTRATOR:ESPARZA, DANIELFACILITY TYPE:
735
ADDRESS:8218 MAPLE GROVE LNTELEPHONE:
(661) 587-9499
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:4CENSUS: 4DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Eric CoronadoTIME COMPLETED:
11:11 AM
ALLEGATION(S):
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Staff slapped client in care
INVESTIGATION FINDINGS:
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On 8/31/23, Licensing Program Analyst (LPA) M. Medina conducted a subsequent visit. LPA introduced self and allowed entrance by House Manager, Administrator Eric Coronado contacted by telephone and arrived a short time later to conduct visit.

LPA Medina conducted interviews with R1, and staff during visit.

The Department investigated the allegation of staff slapped client in care, based on interviews, the complaint is SUBSTANTIATED. R1 was having a behavior on the day incident occurred. R1 became physically aggressive, destroying furniture in the facility, S2 attempted to de-escalate R1 by extending their arm to R1's chest.

Deficiency cited on the attached 9099D.

Exit interview conducted. A copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 24-AS-20230413141153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: INDEPENDENCE AT CENTENNIAL GROVE
FACILITY NUMBER: 157203519
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
80072(a)(1)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other
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Facility conducted training after incident occurred with all staff. Training records and zoom sign in sheets provided to LPA during complaint visit.
DEFICIENCY CLEARED DURING VISIT
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persons.
***This was not met as evidenced by R1 became physically aggressive, destroying furniture in the facility. S2 attempted to de-escalate R1 by extending their arm to R1's chest.
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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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2